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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a myoelectric prosthetic arm for the left upper extremity for treatment of his congenital absence of left arm above elbow. The physician reviewer found that the records demonstrate that this patient meets the criteria for the requested myoelectric prosthesis. The patient has an amputation above the wrist, has sufficient ability to control the prosthesis, and the patient is free from interfering comorbidities. In addition, the patient can activate the prosthesis and standard body powered prostheses are insufficient for activities of daily living. Moreover, there are no environmental factors to preclude use of the requested device. In this case there is documentation of concurrent bilateral leg amputation and change in living status which requires more control from the prosthesis for activities of daily living than the current body powered hook prosthesis can deliver. Accordingly, the requested myoelectric prosthetic arm is supported as medically necessary for treatment of this patients medical condition.  Final Result:  The reviewer determined that the requested device 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 orthopedic surgery and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.   In addition, the reviewer holds a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee requested authorization and coverage of Protopic. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees granuloma annulare.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a four-year-old male enrollee has requested Gamunex intravenous immunoglobulin (IVIG) for treatment of the enrollees infantile spasms.  Findings:  Two physician reviewers found that this young patient has been tried on the standard medications with little success. His provider has recommended treatment with intravenous immunoglobulin (IVIG) therapy, which was denied by the Health Plan, as it is thought to be experimental. The available medical literature provides multiple studies attesting to the benefit of IVIG for treatment of infantile spasms when other standard medications fail to produce a positive outcome. Based on the current scientific data, there is sufficient evidence to suggest that IVIG should and can be used for patients who have failed conventional therapies. Given that this patients condition has been resistant to various standard medications and there is data to support the efficacy of IVIG in infantile spasms, this patient should be approved for treatment with IVIG.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female has requested approval for osteochondral allograft surgery for treatment of her kneecap cartilage loss and subchondral bone involvement.   Findings:  Two physician reviewers found that the patient has a history of a chondral injury to her left patella. An MRI of her left knee showed advanced chondromalacia patellae with cartilage irregularity on both sides of the joint. The patient underwent a left arthroscopic chondroplasty of her patella. A 1 mm x 2 mm lesion was found on her medial facet. The provider recommended that the patient have an osteochondral allograft surgery to her left knee as she had failed all standard therapies. In his appeal letter, the provider indicated that the kneecap supports very large weight bearing loads in normal life and it is the thickest cartilage in the body for this reason. He noted that biomechanics and other studies show that the kneecap supports up to six times body weights with bending, walking or climbing stairs. The provider noted that because of the patients young age, it would be inappropriate to recommend she undergo a total knee replacement.  There is a paucity of scientific data supporting the clinical effectiveness and superiority of osteochondral allograft for patellar defects at this time. Allograft is approved for use for weight bearing surfaces of a limited degree with respect to the femoral condyle, but not the patellofemoral joint. Therefore, there is inadequate evidence that the proposed osteochondral allograft surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for paramedic services. Findings:  The physician reviewer found in this case, the patient was experiencing pain in his mouth for three days following dental surgery. The paramedics report does not describe any difficulty breathing or swallowing. The patients symptoms were not sudden in onset or severe in nature, and do not support that the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned

The patient is a 32-year-old female who underwent bilateral mammaplasty in 2004, which she states has left her with asymmetry of a significant degree. Her board certified plastic surgeon has requested authorization for revision of her reconstructed breasts. The Health Plan has denied the request indicating the requested procedure is not medically necessary as the documentation indicates that the likely intervention is for cosmetic reasons.Records reviewed include a frontal view photograph revealing recently operated upon asymmetric breasts. The records submitted note significant scars distorting the right breast. The proposed procedure would correct the patients asymmetry and address her scars. This evidence and other information provided demonstrates the requested procedure would be to correct or repair abnormal structures of the body caused by trauma or disease to create a normal appearance to the extent possible. Therefore, I have determined the requested procedure is reconstructive in nature and medically necessary. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services. In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is indispensable in determining the necessary and appropriate level of care for adults to ensure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. Using LOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm, (2) functional status, (3) medical, addictive and psychiatric comorbidity, (4) recovery environment (a. stressors and b. supports), (5) treatment and recovery history, and (6) engagement. The composite score is then used to determine the level of care needed.Using the six LOCUS dimensions to determine the necessary level of care for the patient during the period in issue, the patient had no risk of harm, as evidenced by the lack of current suicidal ideation (score=1). She demonstrated a fairly functional level in school (score 2-3). There were no recent substance issues and she was overall medically stable with no acute co-morbidities (score=2). The records indicated she had a stable living environment (score=2) and a supportive recovery environment (score =2). The patient demonstrated moderate levels of response to treatment (score =3). She demonstrated good cooperation with the treatment (score=2). Thus, the patient had a composite score of 14-15. This score correlates with a treatment intensity level of two, which is low-intensity, community-based services. It indicates that the patient could have safely been treated in a less restrictive setting during the period in issue. Therefore, the Intensive Outpatient Program (IOP) services provided during the period in issue were not medically necessary for treatment of the patients medical condition.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 psychiatry, with subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee, with a prior history of coronary artery disease (CAD), has requested authorization for a CT angiography.Findings:  Two physician reviewers found that although significant coronary disease was found in this patient, CT angiography is not indicated or proven to change outcomes by large randomized clinical trials. Currently, CT angiography is considered investigational and is not a substitute for cardiac catheterization or nuclear spect imaging. Additionally, the test is not supported by the American Heart Association (AHA).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that per the 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 comorbid conditions regardless of fibrosis. According to the guidelines, patients taking a specific HIV medication should not be treated with Viekira Pak due to a drug interaction resulting in significant gastrointestinal and neurologic side effects.  Additionally, the guidelines state that Viekira Pak should be used with ribavirin when treating genotype 1a. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% . For these reasons, the requested Viekira Pak is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is 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 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: Overturned

Nature of Statutory Criteria/ Case Summary:  According to the patients medical record, this is a patient with systemic lupus erythematosus (SLE, an autoimmune disease).  The patient has a low positive ANA (a screening test to detect autoimmune diseases) , malar rash and joint pains. The provider prescribed Benlysta (belimumab) 200 milligrams weekly and stated the patient has tried and failed prednisone, methyl prednisone, gabapentin and Plaquenil. The patient experiences pain, chills and nausea when unable to take Plaquenil. The patient has taken Plaquenil for 10 years but recently developed a rash due to Plaquenil use. The Federal Drug Administration has approved Benlysta for autoantibody positive SLE, excluding renal and central nervous system disease (neither is present in this case). It is most useful in joint and skin disease, which is what the patient has. Benlysta is added to standard medication such as Plaquenil or steroids. ANA titers can vary with time, and after ten years, the current presence of a borderline titer of 1:40 does not preclude the diagnosis of SLE. The same can be true for more specific antibodies such as anti-Sm and anti-DNA. The patient has symptoms in the skin and joints without Plaquenil due to a reaction to that medication, so the patients options are Benlysta or medications that have toxicities at least equal to and more likely more severe than Benlysta. Steroids have not provided the patient with good relief, and one would not want to rely on them for chronic management. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology        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 similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 32-year-old female enrollee has requested first trimester pregnancy testing for treatment of her medical condition. Findings:  The physician reviewer found that this patient was evaluated in an office visit by an obstetrician. She presented reporting a positive home pregnancy test. She denied weight loss, headache, chest pain, difficulty breathing or urinary frequency. The patient did not report any vaginal bleeding or discharge. Her vital signs revealed a blood pressure of 100/60 and her physical exam was otherwise normal. A pap smear was taken and sent for analysis. An ultrasound was obtained showing a 6-week, 3-day intrauterine gestation. Blood tests were ordered for a urinalysis, obstetrical panel, HIV test, parvovirus, and varicella assay. No medical intervention or medications were administered. 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. This patient sought medical attention on an outpatient basis for evaluation of her pregnancy. She was not experiencing any acute symptoms at the time of her initial visit. The patient did not report vaginal bleeding, discharge, or pelvic pain. Her physical exam was normal. There was no medical indication for an emergent ultrasound on an asymptomatic patient in this case. Additionally, while the screening exams ordered may be indicated for routine obstetrical care, the tests ordered in this patients case were not required on an emergency basis. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergent care to jeopardize her health or the health of her fetus in this situation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay for evaluation of the enrollees cutaneous melanoma.Findings:  Three physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a thin melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its use. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in dermatology and are actively practicing. The reviewers are an experts 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 female who has lost over 100 pounds following gastric bypass surgery. She has since developed excess abdominal skin. The patient has requested authorization and coverage for an abdominoplasty. The Health Plan has denied this request indicating the requested procedure is cosmetic in nature.The patient is requesting authorization for abdominoplasty to relieve back pain and intertriginous dermatitis. The lack of significant rash on her examinations indicates that whatever dermatitis may be occurring can be controlled with conservative medical therapy. Furthermore, based upon the submitted photographs, it does not appear the excess abdominal skin pictured would be a significant factor in the patients lower back pain. Thus, the proposed abdominoplasty is not likely to have greater therapeutic effect than conservative medical therapy in this situation. Accordingly, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a home setting for the patients already approved speech therapy services. Medical literature recommends early intervention for children with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists, even under three years of age. In a systematic review, researchers conclude that behavioral-based interventions are evidence-based to introduce speech to non-verbal individuals with developmental disabilities. Researchers describe that treatment of individuals with autism spectrum disorder as involving intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Researchers report, Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder. While current medical literature thus supports the use of speech therapy for children with autism spectrum disorder, in this clinical setting, there is a lack of evidence regarding the medical necessity of home-based speech therapy. The records do not document that this patient has any medical conditions that prevent him from leaving the house. In this patients case, a home setting for speech therapy is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, a home setting for the patients already approved speech therapy services is 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 board certified in neurology with special qualification in child 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

The patient has requested authorization and coverage for dupilumab (Dupixent) 300 mg/2 ml and injections of 600 mg injected subcutaneously on day one and/or injections of 300 mg every other week. The patient was diagnosed with dermatitis. Physical examination findings included hyperpigmented plaques on the posterior proximal interphalangeal areas of the hands. Erythematous scaly plaques were noted on the digits of both hands. Researchers noted, dupilumab is the first U.S. Food and Drug Administration (FDA) approved therapy for moderate-to-severe atopic dermatitis. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, dupilumab (Dupixent) 300 mg/2 ml and injections of 600 mg injected subcutaneously on day one and/or injections of 300 mg every other week are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 dermatology 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 male enrollee requested Serostim 4 mg daily for medical treatment of his lipodystrophy secondary to human immunodeficiency virus (HIV) medications. Findings:  The physician reviewer found that as noted by the U.S. Food and Drug Administration (FDA), Serostim is indicated for the treatment of HIV patients with wasting or cachexia to increase lean body mass and body weight, and improve physical endurance. The records indicate that due to documented and stated findings of lipodystrophy previously, this patient began taking Serostim. At the time, he was noted to have significant lipoaccumulation of the abdomen and muscle wasting of the face, arms, legs and buttocks. Based on the documentation, the patient appears to have improved from this status. He reports that his waist size is down significantly and that he has regained appropriate muscle mass. However, the medical documentation provided for this review does not adequately define any current lipodystrophy, including the amount of continued lipoaccumulation or lipoatrophy present or other documentation to warrant continued treatment. Without detailed examination of the patients current lipodystrophy including lipoatrophy or lipoaccumulation, further treatment with the requested Serostim 4 mg daily is not medically necessary.