Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for daily injections of human growth hormone (somatropin). Growth Hormone Deficiency (GHD) is a medical condition in which the body does not produce enough growth hormone (GH). A study recognized effects which include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance. Another study found GHD is also appreciated to be a factor in increased mortality from cardiovascular disease. Growth hormone replacement therapy can provide a number of measurable benefits to GH-deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. An additional study found that in patients with known hypothalamic or pituitary disease, doctors can establish the diagnosis of growth hormone deficiency with high sensitivity and specificity when there are 3 or 4 additional pituitary hormonal deficiencies or a sub-normal IGF-1 level. To establish the diagnosis in patients without these criteria requires provocative growth hormone stimulation. In this case, this patient does not have a documented history of growth hormone deficiency and does not meet the criteria for diagnosing growth hormone deficiency. Endocrinology progress notes state that while the patient had a recent IGF-1 level that was low, his previous levels were normal. Progress notes indicate that it is possible that the patients obesity and other comorbidities may be causing a decrease in his IGF-1 rather than overt growth hormone deficiency or hypopituitarism. Under these circumstances, the requested daily injections of human growth hormone (somatropin) are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a brain single photon emission tomography (SPECT) scan with dopamine transporters (DaT) scan (CPT 78607 and HCPCS A9584). Parkinsons disease is a clinical diagnosis characterized by asymmetric onset of tremors, slowed movement, stiffness, and altered gait. In patients with equivocal signs and symptoms of Parkinsonism, or those who do not respond to treatment, SPECT with DaT can help confirm a diagnosis. SPECT with DaT can help image dopamine transporter in the brain, which is lost in Parkinsons disease. In this case, the patients clinical features described in the records are concordant with the clinical diagnosis of Parkinsons disease. In addition, the patients treatment regimen includes medical therapy for Parkinsons disease that has been adjusted based on her response. Results from additional imaging would not likely lead to a different diagnosis or an alteration in the patients current treatment plan. For these reasons, the requested brain SPECT scan with DaT scanning (CPT 78607 and HCPCS A9584) is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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: Urgent Care
Decision: Upheld

A 41-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that this patients earache had commenced gradually over two days. Although she had some congestion and sore throat, the patient was not experiencing fever, chest pain, or shortness of breath. There was no sudden decompensation or change in her condition. She was described in the medical record as being in no distress and her vital signs were normal. The patient did not require any testing or other medical intervention in the emergency department; she only required ear drops, and an oral antibiotic was prescribed. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe she was at risk of serious jeopardy to her health, serious impairment to bodily function or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet the criteria for an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested  magnetic resonance imaging (MRI) of the lumbar spine for medical evaluation of her back pain.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested diagnostic procedure.  This patient continues to have low back pain with radicular symptoms despite completing 22 physical therapy visits in 2012.  In this case, the patients persistent symptoms despite extensive physical therapy are indications for further imaging.  National Imaging Associates, Inc. guidelines do not specify a timeframe for conservative management when there is exacerbation of chronic low back pain.  In addition, while surgery is not contemplated at this time, the request for pain management intervention is reasonable and such consultation routinely requires MRI scan prior to seeing the patient.  Often, MRI serves as a roadmap for intervention via injection by the pain management specialist.  All told, the requested MRI of the lumbar spine is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for internal medicine with subspecialty certifications in medical oncology and hematology. Hereditary hemorrhagic telangiectasia (HHT) is a genetic disease that causes multiple arteriovenous malformations in various organs. Common presentations include epistaxis, mucocutaneous arteriovenous malformations, and gastrointestinal bleeding. High output heart failure is significantly advanced disease that requires immediate intervention. These arteriovenous malformations are not amenable to ablation but have been shown to respond to treatment with bevacizumab (Dupuis-Girod, et al.). This patients records document that she has failed treatment with bevacizumab. Her provider has recommended treatment with Votrient. Faughnan and colleagues reported that Votrient is a tyrosine kinase inhibitor that blocks VEGF [vascular endothelial growth factor] receptors potentially serving as anti-angiogenic treatment for HHT. The authors found that patients showed a decrease in epistaxis and some showed sustained improvement. Given this support, the requested Votrient (pazopanib) is medically necessary for 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 reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 has requested authorization and coverage for abdominoplasty. According to the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. The ASPS noted that a cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. The medical records do not support an indication for abdominoplasty, which would not address a documented functional deficit due to the presence of the patients pannus. Therefore, the requested abdominoplasty is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

The patient is a 51-year-old woman with a history of obesity, hypertension, elevated cholesterol and a back injury for which she underwent fusion surgery. She underwent an EBCT scan on 11/4/02 to assess for coronary calcification. At that time, there was no history or documentation of any potential anginal discomfort. The Health Plan has denied coverage for the EBCT scan on the basis that it was not medically necessary for evaluation of the patients medical condition.In this circumstance, the patient has a few cardiac risk factors such as obesity, hypertension, and elevated cholesterol, but no symptoms to suggest an active coronary process. Current guidelines already exist and are being continually updated by expert communities in the field pertaining to risk factor modification and treatment. To date, these guidelines do not incorporate routine use of EBCT in this patients population. In addition, there has been no incremental value demonstrated for EBCT beyond that already achievable by a combination of current clinical risk indices and stress testing (when necessary and indicated). Therefore, I have determined that the EBCT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 26-year-old female enrollee has requested authorization and coverage for weekly individual outpatient therapy. Findings:  The physician reviewer found that the American Psychiatric Association (APA) noted that regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. If 4-8 weeks of treatment do not yield at least moderate improvement (20% diminution in symptoms), the clinician should thoroughly review and reappraise the treatment plan. In this case, the patient has improved with treatment. She has also expressed her preference for outpatient services rather than more restrictive PHP, which is not indicated at this time. In terms of outpatient therapy, current mental health practice is focused on aggressive treatment of psychiatric illness in the acute phase of illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Thus, weekly sessions are oftentimes indicated, particularly following psychiatric hospitalization. Psychotherapy is a first-line intervention for depression, anxiety, and eating disorder, especially in this clinical setting. Thus, weekly therapy is appropriate and reasonably expected to help the patient consolidate her recent treatment gains and prevent a more serious episode of illness. The medical records support an initial eight week course of weekly individual outpatient therapy as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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

An enrollee has requested authorization and coverage for biofeedback therapy. The American College of Gastroenterology (ACG) guidelines for the management of benign anorectal disorders recommend anorectal manometry to determine whether a functional disorder is present, and a physical functional performance test, such as a balloon expulsion test, when evacuation or outlet disorder is suspected. In this case, both of these tests have been performed. The patient has failed multiple medical therapies and has had symptoms and testing consistent with constipation due to pelvic floor dysfunction or dyssynergia. Thapar and colleagues have found that for patients who do not demonstrate significant structural abnormalities, such as this patient, biofeedback therapy can be effective. Under these circumstances, the requested biofeedback therapy is medically necessary to treat the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

The parent of a four-day-old male enrollee has requested reimbursement for emergency room services provided. The Health Plan has denied this request indicating that the enrollees condition was not emergent in nature. Findings:  The physician reviewer found that the patient, a then four-day-old male, was brought to the emergency room by his parents due to six hours of crying, decreased oral intake and concern that the patients skin looked yellow. The emergency room physician noted the patient looked very appropriate, interactive and otherwise well. Upon examination of the eyes, the physician indicated that he did not see any jaundice. The patient was not crying in the emergency room and was resting comfortably. His bilirubin was 9.3. The physicians impression was fussy baby. Under Health and Safety Code 1317.1, an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1) placing the patients health in serious jeopardy; 2) serious impairment in bodily function; or 3) serious dysfunction of any bodily organ or part. This patient met prudent layperson criteria for emergency care because it was reasonable for a parent in this situation to suspect that an infant was suffering from an emergency medical condition given the duration of the patients crying, the lack of feeding and the change in skin color, all of which were abnormal for this patient. Some of these symptoms are also symptoms of potentially life threatening illnesses including sepsis, jaundice, and gastrointestinal disorders of the newborn. The patients symptoms were of sufficient severity (including prolonged crying and refusal to feed) such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to health. For these reasons, the parents decision to seek treatment in the emergency room was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male has requested additional fat grafting and procedures which involve liposuction and mastectomy for gynecomastia, suction assisted lipectomy, revision of reconstructed breast, and tissue grafts, other, e.g., paratenon, fat, dermis for treatment of his gynecomastia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  As evidenced by the submitted photograph, the patients condition does not constitute an abnormal structure of the body.  Based upon the photograph, the concavity and fold are not of a severity which constitutes an abnormal condition.  Additionally, there is no documented functional deficit.  Thus, the surgery is not being performed to improve function.  All told, additional fat grafting and procedures which involve liposuction , mastectomy for gynecomastia, suction assisted lipectomy, revision of reconstructed breast, and tissue grafts, other, e.g., paratenon, fat, dermis are not reconstructive in nature and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old woman with chronic obstructive pulmonary disease who is requesting authorization and coverage for a portable nebulizer. She takes albuterol and Atrovent by nebulizer. She also apparently uses Combivent. The Health Plan indicates a portable nebulizer is not medically necessary for treatment of the patients condition.The clinical information provided does not demonstrate a medical need for a portable nebulizer. Metered-dose inhalers (MDI) are generally considered as appropriate as the nebulized treatment. There is no indication an MDI (with or without a spacer) will not be effective for this patient when she is outside the home. Therefore, I have determined that 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy, at a frequency of one time per week for 45 minutes. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees mixed receptive-expressive language disorder. Findings:  The physician reviewer found that rReview of the submitted documentation demonstrates the medical necessity of the request for speech therapy at the frequency of one time per week for 45 minutes. The study by Ohare and Bremner found that treating speech and language disorders early leads to better outcomes. In this case, the patient has made progress, but the patient continues to have a few areas that are not age appropriate. In addition, the Health Plan indicates that an assessment and/or re-evaluation should be done. This recommendation is medically reasonable, however speech therapy should not be stopped pending the results of testing. Based on the clinical documentation submitted for review, the request for speech therapy at the frequency of one time per week for 45 minutes has been established as medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 authorization and coverage for acupuncture for treatment of the enrollees neck pain and back pain. Findings:  The physician reviewer found that the records indicate that this patient has had extensive acupuncture treatment for over three years and 51 treatments with no documented improvement. The patient has been recommended for surgery but has declined. In this clinical setting, acupuncture is not indicated as more effective than standard medical treatment for chronic pain. Given the lack of improvement in the acupuncture records provided for review, further treatment is unlikely to produce improvements not already realized. Thus, the requested acupuncture is not supported as medically necessary for treatment of this patients medical condition. 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 board certified in acupuncture 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.