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 denosumab (Prolia) treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that the medical records fail to demonstrate the medical necessity of the requested medication. Although the patient has tried Fosamax, the documentation do not show that she has tried intravenous bisphosphonate in the form of Reclast. The submitted records do not indicate that this patient has a contraindication to or an inability to tolerate bisphosphonate therapy. 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 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

A 62-year-old male enrollee has requested proton beam therapy for the treatment of his prostate cancer. Findings:  The physician reviewer found that proton beam therapy for prostate cancer is not experimental, but is not medically necessary given that other treatment approaches (IMRT with/without IGRT) are highly effective and well tolerated. There is no literature to state that the outcome after proton therapy, either with respect to PSA control, tumor control or toxicity is better than IMRT. Thus, while radiation or surgery may be medically necessary, proton beam therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a patient has requested authorization and coverage for Omnipod DASH insulin pump and supplies. Findings: General practices for healthy pump sites are similar across different systems, including changing the site of cannula every two to three days to avoid infections, avoiding areas of broken skin, and rotating and varying injection sites. In this case, the provider reported that the patient has experienced fluctuations in blood sugar levels with a different pump due to how often the patient has to disconnect from it. The Omnipod DASH insulin pump does not require tubing and is not removed for exercise and activity. The medical evidence supports the requested equipment in this clinical setting. Therefore, Omnipod DASH insulin pump and supplies are medically necessary for the 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 breast implants or fat injections to increase breast size. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. The patient underwent a bilateral breast reduction. She reports that her breasts are too small and unequal in size following the procedure. She is 5 feet tall, weighs 160 pounds, and has a BMI of 31.3, with a markedly globular abdomen. Her functional symptoms of back and neck pain with intertrigo have been improved since she underwent breast reduction surgery. There is no documentation of any functional issues related to breast size. Therefore, breast implants or fat injections to increase breast size is not medically necessary. Further, the requested surgery is not being performed to correct or repair an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor, or disease. The patients photographs show reduced breasts with shape and size within normal range. The breasts are resting on a globular and protuberant abdomen. The patients axillary tissue is within normal limits. Moreover, no functional issues have been documented in relation to the patients breast size. The appearance of the patients breast shape and size are within the range of normal for a female habitus. Since the requested breast augmentation will not improve function or create a more normal appearance, the requested breast implants or fat injections to increase breast size is not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and are 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for pegfilgrastim 6 mg (Neulasta) injections. The U.S. Food and Drug Administration (FDA) approves the use of pegfilgrastim (brand name Neulasta) to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. Researchers note that there is a high incidence of febrile neutropenia post adjuvant chemotherapy with docetaxel, carboplatin and trastuzumab for early-stage breast cancer. In this case, given that the patient reports significant burden and fatigue from filgrastim, the requested medication is medically indicated. Therefore, pegfilgrastim 6 mg (Neulasta) injections is medically necessary 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 reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prometrium. The Health Plan has denied this request indicating that the requested name brand medication is not medically necessary for treatment of the enrollee who has a history of menopausal syndrome and fibromyalgia syndrome. Findings: The enrollee and the enrollee's provider state that HRT is appropriate to manage the patients menopausal symptoms. This therapy is well supported by the American College of Obstetricians and Gynecologists (ACOG) and the North American Menopause Society.  In order to safely take estrogen to reduce symptoms, this must be balanced by a progesterone to protect the enrollees endometrium from the possible development of cancer. There are different progesterone preparations available for this purpose. However, evidence based recommendations support the use of micronized progesterone as the first choice as it the safest progesterone preparation currently available. The use of name brand medications is supported by ACOG in enrollees who have been unsuccessful with generic medications. Since this patient has tried and failed the generic form of micronized progesterone, it is medically necessary for the enrollee to use the name brand Prometrium. Therefore, Prometrium is medically necessary for the treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested name brand medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 parents of an 8-year-old male enrollee requested authorization and coverage of speech therapy for the treatment of speech difficulty.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested magnetic resonance imaging (MRI) of the breast for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested MRI of the breast is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to Leung and Sickles, Developing asymmetry is an uncommon finding. When this sign is identified on screening and diagnostic mammography, the likelihood of malignancy is sufficiently high to justify recall and biopsy. Thus, the use of breast MRI to further evaluate the patients left breast mammographic focal asymmetry is supported by the peer-reviewed literature.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for urgent care services. Findings: The physician reviewer found that the issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services at issue were not necessary for treatment of an emergency medical condition. This patient presented the day following an ankle injury sustained while running. Although the patient had pain with weight-bearing she was able to ambulate with a steady gait. She denied any neurologic deficits. Tenderness was present without skin discoloration or swelling. The patient was neurovascularly intact. The patient did not receive any pain medication in the urgent care facility and was discharged with an ace bandage. Although it was reasonable for this patient to seek medical attention, there is no documentation to support that the patient received 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: Upheld

The patient is a 43-year-old woman with a history of cervical fusion 15 years ago. An MRI revealed diffuse disc bulging. Surgery has been suggested to alleviate the patients pain. The Health Plan has denied authorization and coverage for surgical intervention on the basis that it is not medically necessary.The patient has undergone prior surgery. Her symptoms at this time are not progressive. Based upon the information provided, it does not appear the patient has undergone a trial of conservative treatment. Unless there is progressive weakness, surgery should not be utilized until all other means are exhausted. The patient is not a surgical candidate until she has attempted physical therapy and/or chiropractic care, medications, and epidural injections. Therefore, I have determined that the requested procedure is not medically necessary for the 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: An enrollee has requested authorization and coverage for Euflexxa injections in both knees for treatment of the enrollees knee pain. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient has been diagnosed with bilateral severe knee osteoarthritis.  He presented with worsening knee pain.  He has been treated with anti-inflammatory medications, with mild relief.  He has undergone prior series of Euflexxa injections, with reported significant sustained pain relief.  These injections have been recommended to delay total knee arthroplasty.  The medical evidence supports the requested services in this clinical setting.  All told, the requested Euflexxa injections are medically indicated 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 physician 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 41-year-old female enrollee has requested for osteopathic manipulation for treatment of her neck and upper back pain. Findings:  The physician reviewer found that the review by Posadzki and Ernst specifically reviewed the osteopathic manipulation literature with respect to musculoskeletal pain and concluded that, the data from the literature fail[ed] to produce compelling evidence for the effectiveness of osteopathy as a treatment of musculoskeletal pain. This finding is consistent with other studies examining spinal manipulation (Assendelft, et al.). Overall, no significant benefit would be expected with the requested therapy, over an independent exercise program, relative rest, self-applied palliative modalities and pharmacotherapy. Additionally, the documentation provided does not support any specific, clinically relevant benefit that has been achieved to date, which could be clearly attributed to osteopathic manipulation. The records indicate the patient continued to have severe pains despite the osteopathic manipulation that was being provided. Going forward, no significant, sustained benefit would be expected with further osteopathic manipulation for this patient. Thus, the requested osteopathic manipulation is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer. Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone or any available standard modality. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are 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: Overturned

The patient has requested authorization and coverage for Xifaxan 550 mg tablet three (3) times daily for 10 days. The patient has been diagnosed with irritable bowel syndrome with diarrhea (IBS-D). Researchers reported that in a phase three study of patients with relapsing symptoms of IBS-D, repeat rifaximin treatment was efficacious and well tolerated. Authors also states that rifaximin appears to be safe and well tolerated in the treatment of non-constipation irritable bowel syndrome with no increased risk of infections, including clostridium difficile infection and no substantial differences in any adverse events versus placebo. In this case, the patient had diagnoses including IBS-D and SIBO with symptoms including diarrhea, pain, bloating, and discomfort. The patient had tried and failed over-the-counter medications. The medical evidence supports the requested medication in this clinical setting. Therefore, Xifaxan 550 mg tablet three (3) times daily for 10 days is medically necessary 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 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 patient has requested authorization and coverage for post-acute care rehabilitation center services. The records provided for review do not support the medical necessity of post-acute care rehabilitation center services for treatment of this patient. The patients current nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no indication for inpatient rehabilitation services with close physician or nursing supervision. The patients vital signs are stable and the provider has recommended discharge to a non-acute inpatient rehabilitation program. The patient may benefit and participate in additional physical and occupational therapy on an outpatient basis. The patients functional status does not require that these services be provided in an intensive rehabilitation facility. All told, the requested post-acute care rehabilitation center services are not medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 parent of an 11-year-old female enrollee has requested  speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Based upon the documentation provided, the patient is intellectually disabled. At the age of 11 the patient is unable to read and did not know her address or telephone number. Her IEP has been only partially successful in attempting to teach the patient to sound out single letters. The patient has made some progress in speech development. As she has some ability to develop speech, the usual and customary medical practice would be to initiate speech therapy. The medical literature does support speech therapy for intellectually disabled children. Law and colleagues, report that intellectually disabled children with speech delay can be successfully treated, as confirmed in a meta-analysis of multiple medical journal articles. Goorhuis-Brouwer and Knijff specifically deal with speech-delayed children of normal intellect and those who are intellectually delayed; the authors conclude that members of both patient populations are candidates for successful speech therapy. Therefore, it is medically necessary for this patient to receive speech therapy.