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

The patient is a 52-year-old female with a diagnosis of chronic Lyme disease. She evidently had a positive Lyme Western Blot in May 2005 and coinfection with Ehrlichiosis. Her symptoms consist of poor balance, vertigo, blurry vision, headaches, confusion, joint pain and difficulty with concentration. No abnormal exam findings are noted. An MRI of the brain revealed a few small foci in subcortical white matter, which may be consistent with neuroborreliosis. The patient has been treated for four months with four antibiotics. She is seeking an additional twelve weeks of therapy with intravenous ceftriaxone. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.The above-mentioned study by Klempner, et al. did not demonstrate any efficacy to prolonged antibiotic therapy. In addition, studies by Kaplan and Krupp have not shown any benefit to antibiotic therapy beyond thirty days. Although individual experience, case studies, and non-placebo controlled trials are important in advancing the science of medicine, they cannot be the basis for treatment guidelines for larger populations. The body of scientific evidence for the treatment of late stage Lyme disease (Lyme arthritis or neuroborreliosis) is 30 days of intravenous antibiotic, with a possible repeat course. Trials are ongoing for longer courses of treatment, but there is no published data in peer-reviewed journals of double blind, placebo controlled trials showing their efficacy. Thus, there is inadequate evidence to show extended antibiotic therapy will result in a benefit to the patient beyond standard therapy. Based upon the information set forth above, I have determined the requested therapy 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: An enrollee has requested authorization and coverage for brand name Topamax, (not a generic such as topiramateary) for treatment of the enrollees localization related focal epilepsy with complex partial seizures.  Findings:  The physician reviewer found that while generic antiepileptic drugs are appropriate for many patients with epilepsy, there are some patients that are highly sensitive to very small changes in drug preparations. In such cases, patients may have breakthrough seizures when a different generic therapy is substituted for another. In this particular case, this patient has been documented to have breakthrough seizures when generic antiepileptic drugs therapies were utilized. Since persistent seizures cause significant morbidity, it is medically reasonable to use a brand name antiepileptic drug such as Topamax to limit drug level fluctuation and lower this patients risk of seizures. Thus, the requested brand name Topamax, (not a generic such as topiramate), is supported as medically necessary for treatment of this patients epilepsy.  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: Physician reviewer number one is board certified in internal medicine and neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50-100 mg for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.Findings: According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis virus should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing should not be an impediment to coverage and recommend 12 weeks of Zepatier when NS5A resistance testing is not available, as in this patients case. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed regardless of fibrosis stage, and the request for Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The psychiatric services provided were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency consists of a patient who is an imminent danger to himself or to others. In this case, the patient was not an imminent threat to himself or others due to a mental illness. Further, the patient was not enduring a medical crisis secondary to substance use or physical ailments. Indeed, the patient presented with chronic alcoholism. However, his most recent alcohol consumption consisted of five beers two days prior to admission. His blood alcohol level was zero. His heart rate was normal. There was no evidence of a withdrawal syndrome in the initial history and physical. There was no report of prior withdrawal complications, such as seizures, hallucinations or delirium tremens. The patient had no thought impairment, cognitive compromise or suicidal ideation. In sum, upon presentation, the patient was not experiencing an acute psychiatric syndrome or an emergent psychiatric condition. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer ermined the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.  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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to an acupuncturist for treatment of the enrollees abdominal pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested referral. The use of acupuncture for the treatment of chronic abdominal pain is not supported in the peer-reviewed literature. In addition, the documentation submitted for review does not demonstrate the total number of acupuncture sessions completed or reports of any sustained, significant, objective functional improvement. Therefore, based on the lack of peer-reviewed literature supporting the use of acupuncture for ovarian cysts and absence of documentation demonstrating either medication intake reduction, or function activities of daily living improvement with prior acupuncture, the request for a referral to an acupuncturist is not supported as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested referral 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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male who has been treated with chiropractic care for neck and shoulder area pain and a diagnosis of ankylosing spondylitis. The patient has tried medications, physical therapy and chiropractic treatments but states the chiropractic care is the most helpful. His complaints continue however, with no apparent conclusion to his recent plan of care. The patient has requested reimbursement and authorization and coverage for additional chiropractic services. The Health Plan does not consider the services medically necessary and denied his request.It appears from the records provided that the previous chiropractic services were medically appropriate and beneficial to the patient.  However, at this stage of the patients care it would be prudent to pursue consultation with a medical orthopedist or physiatrist for medical evaluation and further treatment recommendations. I would not recommend authorization of additional treatment unless this approach failed to resolve the patients symptoms.  In that event, periodic care with a chiropractor in concurrence with a home program should be authorized to help calm exacerbations.Based upon the information set forth above, I have determined past chiropractic services were medically necessary and the patient should be reimbursed.  Additional chiropractic services are not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee requested real-time intra-fraction target tracking during radiation therapy for medical treatment of her breast cancer.  Findings:  Two physician reviewers found that there is insufficient scientific data demonstrating that the use of real-time intra-fraction target tracking during radiation therapy results in greater clinical benefit compared to other techniques available in this particular setting.  The submitted documentation fails to demonstrate that the patient could not be safely and effectively treated with standard dose-limiting techniques. All told, real-time intra-fraction target tracking during radiation therapy was not likely to have been superior over other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested  for acute inpatient level of care for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the enrollee reported low self-esteem, decreased concentration, low motivation, fatigue, sleep disturbances, anhedonia, feelings of worthlessness and hopelessness, social isolation, passive suicidal ideation and lack of interest in activities. The enrollee also indicated that she only thinks and dreams about food and feels preoccupied with food and severe calorie restriction. The provider notes the enrollee was diagnosed with anorexia nervosa, restricting type and major depressive disorder, recurrent, moderate, malnutrition, low blood pressure, lack of menses and dizziness. On admission, the enrollees global assessment of functioning (GAF) was 35, with 61 the highest within the past year. The enrollee was treated at the acute level of care then was transferred to residential level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a portable oxygen and oxygen conserving device for treatment of the enrollees chronic obstructive pulmonary disease (COPD). Findings:  The physician reviewer found that the accepted criteria for oxygen therapy according to the Centers for Medicare and Medicaid Services (CMS), includes a partial pressure of oxygen (pO2) of 55 or lower, an oxygen saturation of 88% or lower, a pO2 in blood of 56-59, or an oxygen saturation of 89% and congestive heart failure (CHF), pulmonary hypertension, pulmonary heart disease, or a hematocrit greater than 56%. A pO2 of 60 or an oxygen saturation of 90% does not support an indication for oxygen. The providers notes reveal that this patient already has a home oxygen system and a portable system. The only oxygen saturation measurements were 94% and 95% on room air during office visits. These findings do not meet the CMS criteria for oxygen. Thus, the requested portable oxygen and oxygen conserving device are not medically necessary for treatment of this patients COPD. Final Result: The reviewer determined that the requested equipment 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 pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 37-year-old female enrollee has requested emergency services for the treatment of the enrollees condition. Findings:  The physician reviewer found that the patient presented with right lower quadrant pain and symptoms of sufficient severity that a prudent layperson would reasonably seek immediate medical attention for fear of jeopardy to her life and/or bodily organ functions. The differential diagnosis of her presenting symptoms included appendicitis, abdominal abscess, cellulitis, abdominal herniation and other serious disorders.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomography (CT) of the heart without dye with calcium test. Findings:  The physician reviewer found that the records provided for review document that this patient has some coronary risk with dyslipidemia, no anginal quality symptoms, no history of heart disease and a normal cardiovascular physical examination. In this circumstance, guidelines to evaluate and manage dyslipidemia are available and endorsed by several national organizations. These guidelines currently do not recommend screening coronary computed tomography (CT) angiography or screening coronary calcium scanning. Outcomes in patients evaluated with coronary CT angiography have not been shown to be improved compared to outcomes achieved with treatment based on clinical risk and basic lipid profile results alone. Thus, the CT of the heart without dye with calcium test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollees irritable bowel syndrome with diarrhea. Findings:  The physician reviewer found that The records document that this patient has IBS-D, for which Xifaxan has been proven effective. In addition, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. Moreover, Xifaxan has been demonstrated to be safe and effective in randomized placebo controlled trials for IBS-D. In the TARGET-3 trial of over 1,000 patients, Xifaxan 550 mg three times daily was effective with significant symptom improvement. The American College of Gastroenterology guidelines state that Xifaxan is effective for use in this clinical setting. This patient has already been treated with medications including Imodium, Flagyl, vancomycin, and Dificid without success. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of this patients IBS-D. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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 overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in the left knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of left knee pain. She has tried and failed other conservative treatments, including a corticosteroid injection, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc-One injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 sixty-five year-old male who was diagnosed with left renal transitional cell carcinoma with lymph node metastases is requesting authorization of a PET/CT scan.Reviewers Findings:  The reviewing physician found that usefulness of PET/CT scans in urinary tract malignancies is currently unclear.  The reviewing physician found that the Health Plan denial should be upheld.