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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Prolia injections (60 mg every six months for two doses). While pharmacological treatment of patients with prevalent osteoporotic fractures is universally accepted, the treatment of patients at increased risk of fracture due to low bone mass is more controversial. Eriksen noted, According to the World Health Organization criteria for assessment of dual-energy x-ray absorptiometry measurements, patients are considered to have low bone mass (osteopenic), when their bone mineral density T-score of the spine or hip lies between 1 and 2.5. Although fracture risk increases with decreases in bone mineral density, the vast majority of osteoporotic fractures occur in osteopenic patients. This is because even though the risk of fracture is lower in the osteopenia than in osteoporosis, the number of subjects at risk is much higher in the osteopenic range due to the Gaussian distribution of bone mineral density values in the population. Prolia (denosumab) is a bone anti-resorptive drug used for the treatment of osteoporosis and other bone-related disorders. It is indicated as therapy for postmenopausal women with osteoporosis at a high-risk for fracture. Although this patient does not yet have osteoporosis, but does have hypercalciuria and hyperparathyroidism in conjunction with osteopenia. Both of these conditions can lead to worsening of bone mineral density. The patients upcoming dental surgery increases the risk of osteonecrosis of the jaw if the patient undergoes therapy with zoledronic acid. Studies show that the mean maximal serum concentration of Prolia is reached at 10 days, and the mean half-life is 25.4 days, and declines over a period of four to five months. There is no accumulation or change in the pharmacokinetics of denosumab over time in those who take it every six months. Bisphosphonates, on the other hand, have a long in vivo half-life following cessation and may be associated with delayed dental healing and the complication of osteonecrosis of the jaw. Some studies have shown that bisphosphonates have a half-life in bone of up to 11 years. Therefore, Prolia injections (60 mg every six months for two doses) are 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.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested weight loss surgery (laparoscopic band (Lap-Band) or gastric bypass) for treatment of her obesity.  Findings:  The physician reviewer found that from a review of the available records, this patient has a BMI of 39 with diabetes, which meets the generally accepted standard criteria for clinically severe obesity (Colquitt, et al). At this time, the medical necessity of the bariatric surgery cannot be established given the lack of completion of a multidisciplinary evaluation including dietary and behavioral evaluations. Otherwise, this patient has failed dietary efforts and has obtained medical clearance and therefore meets all standard nationally accepted criteria for bariatric surgery (Smith, et al). Therefore, the medical necessity for the requested bariatric surgery has not been demonstrated at this time given the lack of a multidisciplinary evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for MyRisk cancer test for evaluation of the enrollees risk for cancer. Findings:  2/3 of the physician reviewers found that the current medical evidence supports a portion of the services at issue. In this patients case, she was evaluated with a gene panel, which included genetic testing for multiple cancer types. She meets the National Comprehensive Cancer Network guidelines to test for BRCA1 and BRCA2 since she and has a family history of ovarian cancer. As for the genetic testing for other cancers, there is a lack of prospective randomized controlled studies showing improved outcomes correlating the results obtained from similar expanded genetic panel tests with improved overall survival, progression free survival and / or quality of life. These tests have yet to be correlated with improved outcomes. Both National Comprehensive Cancer Network guidelines and American Society of Clinical Oncology guidelines encourage research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers regarding challenges in the use of these tests. Therefore, BRCA1 and BRCA2 testing were likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of the remainder of the genetic testing has not been established. Final Result: 2/3 of the reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 male enrollee requested authorization and coverage of a C.Ti. knee brace for post-operative recovery.  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 equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for GeneSight genotype testing performed for evaluation of the enrollees behavioral health conditions.Findings:  The three physician reviewers found that the submitted documentation does not demonstrate the superior effectiveness of the services at issue.  The documentation provided does not indicate specific medication doses used, length of medication trials or combinations of medications tried and failed. The records do not document that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence-based psychotherapy trials.  It is also not clear whether the patient has attempted psychotherapy. The literature supports outpatient treatment as well as family therapy in managing suicidal ideation and behaviors for adolescents. The current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis, such as dialectical behavioral therapy.  The medical evidence does not support the use of pharmacogenomic testing in this clinical setting. Kirchheiner and colleagues noted there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice.  Thus, GeneSight genotype testing performed was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 physician reviewers are board certified in psychiatry and are actively practicing. The 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the MitraClip procedure for treatment of the enrollee, who has a history of mitral regurgitation. Findings:  The physician reviewer found that in this patients case, the records document severe mitral regurgitation due to flail A1 segment with chordal rupture as a result of prior endocarditis in 2013. The medical records do not support a contraindication to open surgical repair. Moreover, the regurgitant jet is documented to be very eccentric and originating from A1 segment. Inclusion criteria in a trial required that the primary regurgitant jet originate from malcoaptation of the A2 and P2 scallops of the mitral valve. As noted by Nishimura and colleagues, current guidelines support percutaneous mitral valve repair as a class IIb indication only in patients with reasonable life expectancy who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal goal directed medical therapy for heart failure. In a randomized trial, the MitraClip procedure was found to be safe but less effective than surgical repair because residual mitral regurgitation was more prevalent in the percutaneous group. 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 internal medicine with sub-specialty certification in cardiovascular 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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with quadriplegic cerebral palsy. The patient is dependent for all activities of daily living. The patients transfers are with the assistance of a Hoyer lift. He is fed and given medication through a gastrostomy tube. From 1/1/19 through 2/15/19, the patient had 23 seizures. The seizures were described as not involving loss of consciousness and the patient was reported as being alert after the seizures. No rescue medications were administered for seizures, and none are listed in the prescribed medication list. There is no report that the patient has had unstable health or emergency room visits. No pressure-related skin issues were noted. The patient has requested reimbursement and coverage for 40 hours per week of private duty nursing that were provided from 1/1/19 forward. The Health Plan denied the request and reported the services at issue are not medically necessary for the treatment of this patient. At issue in this case is whether the requested 40 hours per week of private duty nursing that were provided from 1/1/19 forward was and is medically necessary for treatment of the patients medical condition. The American Academy of Pediatrics guideline for pediatric home care state that intermittent skilled level of care can be provided by a trained caregiver (McConnell, et al.). Level one medically complex level of care includes ventilator, tracheostomy, recurrent or frequent suctioning, oxygen therapy in connection with apnea monitoring, maintenance of intravenous therapy, nutritional support via continuous nasogastric or gastrostomy tube feeding, or presence of a central intravenous catheter. The patient does not have any of the conditions listed under level one, which would require the provision of a trained nurse. The patient is medically stable. He does not have medical needs requiring skilled nursing care. He is on bolus gastrostomy tube feeds, and has not reportedly experienced regurgitation or aspiration. The patients seizures are brief, and he has not required the administration of rescue medication or emergency room visits. Overall, the medical evidence does not support the services at issue in this clinical setting. Therefore, 40 hours per week of private duty nursing that were provided from 1/1/19 forward was not and is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were not and 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 pediatrics with a special qualification in child neurology and subspecialty certification in hospice and palliative 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 18-year-old female has requested acute inpatient level of care for treatment of the enrollees behavioral health problems.  Findings:  The physician reviewer found that a review of the submitted medical documentation supports the medical necessity for acute inpatient hospitalization from the date in question onward. The medical records indicate the patient has been constantly preoccupied with intrusive negative thoughts and OCD rituals around food, was resistant to the calorie plan and requires a highly structured environment with 1:1 supervision for meals and during bathroom time. Daily nasogastric feedings were required to supplement calories during the time period. As per American Psychiatric Association (APA) practice guidelines, acute inpatient hospitalization is indicated when there is a need for supervision during and after all meals, when nasogastric/special feeding is required, when there is poor motivation and preoccupation with intrusive thoughts, and when bathroom supervision is required. This patient meets all of these criteria. Additionally, Herpertz-Dahlmans article in Child and Adolescent Psychiatric Clinics indicates inpatient treatment is warranted when there is rapid weight loss and severe co-morbidity such as depression and OCD or medical complications such as bradycardia. Further, the level of care being provided is also consistent with the Child and Adolescent Level of Care Utilization System.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old female with OB positive stool. Based upon the information provided, the patient has never undergone an endoscopy. The patient has requested authorization for a colonoscopy. The Health Plan indicates the patient does not meet criteria for authorization of a colonoscopy. Therefore, the Health Plan has determined the requested colonoscopy is not medically necessary.The Health Plans denial should be overturned. Based upon the information provided, it appears the patient has never undergone endoscopic evaluation. It is not likely that flexible sigmoidoscopy in a setting of OB positive stool in a 50-year-old patient is likely to be adequate. In light of the unknown etiology of the patients symptoms, as well as her age, a colonoscopy is medically appropriate and indicated. Therefore, I have determined that the requested colonoscopy is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old female enrollee has requested speech/oral function therapies (including Kinesio Taping, oral stimulation and thermal therapy) for treatment of the enrollees swallowing difficulties and cerebral palsy.   Findings:  Three physician reviewers found that this patient is severely neurologically impaired. She had not gained weight over an 18-month period. At 4 12 years of age, her weight was 5 SDs below the average compared to her peers. The patients difficulty in swallowing and excessive oral secretions have prevented adequate caloric intake. The options for therapy include invasive placement of a gastrostomy tube with surgical reduction of the esophagus by a Nissen procedure and a speech pathologist retraining the patient to swallow. The Food and Drug Administration (FDA) approved oral stimulation for swallowing retraining in neurologically impaired patients. Further, there are studies in the scientific publications that demonstrate the effectiveness of oral stimulation therapy for this indication (Ludlow, et al. and Kiger, et al.). Moreover, Otapowicz and colleagues noted the severe problem of dysphagia in young patients with cerebral palsy and the extreme difficulty in teaching these children to feed. In this case, oral stimulation therapy is being combined with Kinesio Taping and thermal therapy as part of a comprehensive treatment program. Although Kinesio Taping and thermal therapy are still being studied, there is adequate evidence to support the utilization of these techniques in a patient as severely affected as this patient. The use of Kinesio Taping and thermal therapy combined with oral stimulation is an appropriate treatment plan that has been shown to be effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a male with Bainbridge-Roper syndrome. Due to feeding difficulties, he has required gastrostomy tube feedings. He has been receiving occupational and speech therapy to assist with oral feedings and is now taking a substantial amount of his calories by mouth. His tube feeds are made at home and blenderized. Per the providers notes, the patient was receiving a total of 16 ounces per day of blenderized tube feedings. Another provider has recommended Nourish formula, 48 ounces per day. In a letter, one provider stated the patient would benefit from liquid Nourish to help advance his nutrition. The use of powder introduces a lot of air, which causes distention and discomfort. At issue in this case is whether 48 ounces of Nourish Liquid Formula, every 24 hours, for a 12-month period (preferred), or any serving of Nourish Liquid Formula every 24 hours, is medically necessary for treatment of this patient. Blenderized tube feedings have been found to be helpful for a variety of gastrointestinal symptoms in tube-fed patients and are being used with increasing frequency. Blenderized tube feedings require access to equipment for both refrigeration and blending of feeds. The records provided for review document that this patient is receiving 16 ounces per day of blenderized tube feedings. He has been receiving occupational and speech therapy to assist with oral feedings and is now taking a substantial amount of his calories by mouth. As the patient is tolerating more oral intake, Nourish Liquid Formula is not required on a daily basis, and would only be expected to be needed a few times per month. As such, the requested 48 ounces of Nourish Liquid Formula, every 24 hours, for a 12-month period (preferred), or any serving of Nourish Liquid Formula every 24 hours is not 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 pediatric 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

A 58-year-old female enrollee has requested for Xolair for treatment of her asthma. Findings:  The physician reviewer found that the scientific literature demonstrates that Xolair is standard of care for patients who have been diagnosed with asthma, have an elevated IgE and have a positive skin test (such as is the case with this patient).
Appeal type: Urgent Care
Decision: Upheld

A 45-year-old male enrollee has requested coverage for past emergency services provided. Findings:  The physician reviewer found that the patient presented to the emergency room (ER) with complaints of a runny nose, nasal congestion, and a cough for one week. The cough was productive of scanty, yellow sputum, and the patient noticed a fever two hours prior to admission to the ER, which resolved with the use of Advil administered at home. His vital signs in the ER were normal except for slightly elevated blood pressure at 139/81, and his pain level was 2 on a scale of 1 to10. No diagnostic testing was performed in the ER. The provider assessed the patient with allergic rhinitis, sinusitis, and cerumen impaction. He was given prescriptions for the antibiotic Zithromax plus Zyrtec, Sudafed, and Motrin for his symptoms and discharged from the ER.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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 documentation indicates the patients symptoms had been occurring for a week except for the fever, which was present two hours prior to the ER visit. His pain level was documented as only 2/10, and his vital signs were essentially normal. No life or organ threatening illness was diagnosed, and the evidence does not demonstrate that a prudent layperson in these circumstances would have sought immediate medical attention. Although the patient reports that he was traveling out of state and was informed by the Health Plan representative that he only had coverage for emergency room treatment, the patients signs and symptoms did not rise to the level that would cause a prudent layperson to reasonably believe he was experiencing a medical emergency. As the patient stated, the purpose of his visit was to obtain antibiotics and symptom relief.