Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent health care services. Per the California Code of Regulations (CCR) section 1300.67(g)(2), Urgently needed services are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plans service area. The records provided for review document that this patient presented for treatment of exacerbation of degenerative arthritis of the right knee or the hallux rigidus of the left great toe. Both of the patients diagnoses are degenerative and there was no likelihood of serious deterioration of the health of the patient from waiting while treatment with conservative treatment modalities. The patients right knee condition is an exacerbation of the underlying medial compartment and patellofemoral degenerative arthritis associated with a degenerative tear of the medial meniscus. There was a trace effusion which did not need aspiration. There is a lack of support for urgent medical services or urgently needed services to prevent serious deterioration of the health of the patient. The second issue was hallux rigidus of the left great toe which is also a degenerative condition and did not constitute an urgent medical condition. As noted in the medical literature, degenerative tears of the medial meniscus are a common condition that can be safely and effectively managed without surgery (Sonesson, et al.). Hallux rigidus also does not constitute an urgent medical condition (Ho and Baumhauer). In light of the foregoing, the medical services were not provided for the treatment of an urgent medical condition as defined in California CCR section 1300.67(g)(2). Final Result: The reviewer determined that the services at issue were not provided for the treatment of an urgent medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested for Avodart 0.5mg for treatment of his benign prostatic hyperplasia. Findings:  The physician reviewer found that Proscar and Avodart are two 5-alpha reductase inhibitors blocking the conversion of testosterone to the active form dihydrotestosterone. This action results in decreased glandular activity. The decreased glandular activity results in decreased prostate volume over many months.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested prednisone for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation supports the requested medication in this patients case.  The records suggest a potential chronic inflammatory demyelinating polyneuropathy (CIDP) presentation primarily with pain and autonomic dysfunction, compounded by functional, non-organic overlay.  He has had some relief with intravenous immunoglobulin.  The medical evidence indicates that steroids can be effective for CIDP.  In this clinical setting, a trial of prednisone is medically appropriate, although the patient should be aware of potential long-term side effects.  There is sufficient support for the requested medication in this clinical setting.  In sum, prednisone is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, patients with diabetes are at risk for fast progression of fibrosis. Guidelines recommend treatment-naive genotype 1 patients be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested  a diffuse tensor imaging study for evaluation of the enrollees severe cognitive deterioration.  Findings:  The physician reviewer found that in this patients case, the use of diffusion tensor imaging would not lead to any change in therapy or add information that would prove useful to his therapeutic team. If diffusion tensor imaging study demonstrated changes consistent with traumatic brain injury, these findings would not change the approach to treatment of the patients underlying psychotic disorder. Use of diffusion tensor imaging is not within the standard of care for a patient with either traumatic brain injury or psychiatric disease and is therefore not medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 50-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that the differential diagnosis of these presenting symptoms includes several potentially life threatening disorders including epiglottitis and peritonsillar abscess. The patient presented to the hospital with fever, chills, and sore throat of sufficient severity that one could reasonably believe failure to obtain immediate medical attention could result in serious jeopardy to health, serious impairment to body functions or serious dysfunction of bodily organs.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient had requested authorization and coverage for (1) acupuncture treatments three (3) times, or (2) acupuncture treatments two (2) times a month. Vickers and colleagues note that, Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Yin and colleagues report, Acupuncture is effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. In this case, the patient reported benefits from prior acupuncture, but without documentation of pre-acupuncture and post-acupuncture baselines for comparison purposes, the total number of acupuncture sessions completed, and measurable, progressive, significant, or objective functional improvement. The records did not indicate a flare-up of the condition, or a re-injury. There is no indication that the patient is currently undergoing an independent conditioning-aerobic program. The documentation did not demonstrate significant symptom reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. Given that measurable, progressive, significant, objective functional improvement has not been documented,  the requested services are not medically indicated. Therefore, (1) acupuncture treatments three (3) times, or (2) acupuncture treatments two (2) times a month are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is licensed acupuncturist, board certified in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female with a five-year history of Type II Diabetes Mellitus who is noted to also have hypertension and obesity. Her blood glucose levels have been well controlled on metformin and Amaryl. The patients hemoglobin A1c was 6.1% prior to beginning Byetta in August 2006. The Byetta was apparently added to her diabetic regimen to help her to lose weight. Over the course of a month the patient lost seven pounds and regained three pounds with a dosage of 5mcg per day of Byetta. The patients endocrinologist would now like to increase the dosage to 10mcg daily. The patients request for authorization of Byetta was denied by the Health Plan based upon a determination that the medication is not medically necessary.This patients blood glucose levels are well controlled on a combination of metformin and Amaryl. Byetta was apparently begun to help the patient to lose weight. Byetta is not medically indicated for blood glucose management for this patient with a hemoglobin A1c of 6.1% and is not generally prescribed solely to assist with weight loss. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested monitored anesthesia care for treatment of her burning sensation in the esophagus.  Findings:  The physician reviewer found that based on the patients medical records, the monitored anesthesia care provided to this patient during the upper endoscopy provided on the date in question was not medically necessary for treatment of this patients medical condition. The patients records indicate that there is no documentation of any medical conditions that would have required an anesthesiologist to be present to administer monitored anesthesia care during the procedure. The American Society of Anesthesiologists practice guidelines include conditions such as intolerance to sedatives, anticipated difficulty with sedatives, severe comorbidities, pediatric patient, pregnant patient, history of drug or alcohol abuse, over age 60, and uncooperative or agitated. The records do not document the presence of any of these conditions. All told, sedation with benzodiazepine with or without a narcotic would have been sufficient for this patients procedure and remains the standard of care. Therefore, the services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male with quadriplegia who is requesting authorization for a fully electric hospital bed. He indicates he previously had a fully electric hospital bed under his old insurance and now his new insurance has authorized a semi-electric hospital bed. A review of the information provided indicates the patient has requested a fully electric hospital bed because he uses the height adjustment feature to help stretch his legs. However, a fully electric hospital bed is not required for this purpose because there are other means for the patient to accomplish this task and this is not the purpose of a fully electric hospital bed. The Health Plan has authorized a semi-electric hospital bed, which allows for elevation of the head of the bed to prevent choking. In addition, a semi-electric bed can address other areas of the patients needs. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Synvisc injections to the right knee. The patient has been diagnosed with bilateral knee osteoarthritis. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent pain relief from a series of Synvisc injections. Furthermore, the patients options are limited, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections to the right knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for ground and air ambulance transport.Findings:  The physician reviewer found that there is a lack of clinical support for the services at issue in this patients case. Per the submitted documentation, the patient was transferred from Torrance, California to Atlanta, Georgia to be near family members.  However, there are long term care facilities within the Los Angeles, California vicinity which could have accommodated the patients transfer from the hospital. The patients transfer to Atlanta, Georgia was due to personal preference. The medical services and the medical care this patient required were available to him within the Los Angeles area. The documentation submitted do not support the ground and air ambulance transportation from California to Georgia. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested 3 treatments of endovenous chemical ablation on the left leg for treatment of her varicose veins.  Findings:  The physician reviewer found that ultrasound guided sclerotherapy (chemical ablation) is inferior in terms of successful large venous closure than other available therapies. In addition, endovenous chemical ablation is used interchangeably with sclerotherapy. Based on the records provided for review, there is inadequate evidence in the records that the endovenous ablation of the left GSV has satisfactorily relieved the patients symptoms. There is an absence of documentation that the patient is experiencing lifestyle limiting symptoms despite GSV ablation. Therefore, the requested 3 treatments of endovenous chemical ablation on the left leg are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 30-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. This patients upper respiratory symptoms had commenced gradually over four days. She had a cough but no shortness of breath. The patient was described as non-toxic. Her lung sounds and oxygen saturation were normal. Varciella is a viral illness that is self-limited and usually requires only symptomatic treatment. While the patients symptoms may have warranted a medical evaluation, her symptoms were not such that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. Therefore, this patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Contour Next One Meter, Contour Next Test Strips, and Microlet Lancets. This patients recent hemoglobin A1C was 5.8. The patient is currently on Metformin XR and Metformin. His provider has recommended use of Contour Next One Meter, Contour Next Test Strips, and Microlet Lancets. One study from Harashima and colleagues reported that self-monitoring of blood glucose (SMBG) levels is helpful to maintain glycemic control in non-insulin-treated type 2 diabetes. The authors concluded that their findings support improved hemoglobin A1C levels in patients with continued SMBG compared to patients who discontinued SMBG for management of type 2 diabetes. A number of glucometers are available which may aid in SMBG. Moreover, medical literature noted that among the current blood glucose monitoring systems, the Contour Next Meter demonstrates excellent accuracy. Therefore, the requested Contour Next One Meter, Contour Next Test Strips, and Microlet Lancets are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested for a CT scan of the chest for evaluation of her right lung nodule. Findings:  The physician reviewer found that according to a review article by Tan, et al, if a solitary pulmonary nodule (SPN) is unchanged for more than two years, it does not require further diagnostic evaluation. A clinical review article by Weinberger also indicates that no further diagnostic workup is needed if the nodule is unchanged for two years. The patient does not demonstrate any significant change in her clinical status. However, should the patient start to demonstrate clinical signs and symptoms such as chronic cough, weight loss, unexplained fevers, hemoptysis, chest pain, etc., then a repeat CT scan of the chest would be indicated.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 15-year-old female with a history of an ACL injury in September 2005. She is status post ACL reconstruction in December 2005. She received six visits of physical therapy from January through March 2006, which documented range of motion of 0-140 degrees with 5/5 strength. The therapist recommended discontinuance of physical therapy with a home program. Since that time the patient has been seen by a therapist at a competitive athletic training program who documented pain at terminal flexion and  4 degrees of knee extension in March 2006 with full range of motion in May 2006. The patient still has some asymmetry from side to side and the therapist documented difficulty with decelerating when running or hopping. A recent physician evaluation has not been provided.At issue is whether competitive athletic training physical therapy was/is medically necessary for treatment of the patients condition.The patient appears to have received a short course of physical therapy, which allowed her to get her range of motion back with some subsequent regression. She then received competitive athletic training physical therapy from March 2006 to May 2006. The patient did not require the specialized services of a competitive athletic training physical therapy program. Although it appears the patient experienced some regression following the authorized course of therapy, it was not necessary for the patient to receive rehabilitation services that were specifically geared to return to sports. The patient could have been appropriately treated with traditional physical therapy. Therefore, I find that the therapy at issue was/is not medically necessary. The Health Plans denial should be upheld. Since it does not appear the patient has recently been evaluated by a physician, she should be re-evaluated by an orthopedist to determine if additional physical therapy (traditional) is warranted based upon her current functional status.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested residential treatment services for treatment of behavioral health problems.  Findings:  The physician reviewer found that to the extent that there was not a dramatic shift in the patients status or treatment plan during the requested period, there is inadequate evidence that the patient was in need of residential treatment for this two-day period.