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

The patient is a 54-year-old male who is requesting a referral to a pain management clinic for a long history of back pain. He has tried physical therapy, which has not provided sustained relief. In addition, the patient does not want to take muscle relaxers or pain medications. The patient has requested a referral to a pain management clinic that offers DRX Spinal Decompression. The Health Plan has denied the request on the basis the requested referral is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. DRX Spinal Decompression is a form of traction and its benefits and efficacy for back pain as compared to conventional treatment has not been established in scientific literature. In fact, traction itself is not of established efficacy for treatment of low back pain. The Health Plans alternative treatment is more clinically appropriate.  As such, there is no medical justification for referral to a pain management clinic. Therefore, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested a second series of Hyalgan injections for the treatment of his osteoarthritis of the shoulders. Findings:  Two physician reviewers found that Hyalgan injections have not been approved by the FDA for joints other than the knee. There is insufficient evidence in the medical literature supporting the use of Hyalgan or any other form of viscosupplementation for the shoulder. Based upon the evidence available to date, the patient should achieve better results with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested Suboxone MIS Film for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Suboxone is a combination medication containing a partial opioid agonist with a full opioid antagonist.  Suboxone is not indicated for the treatment of chronic pain.  This patient reported that he benefitted from methadone in the past.  In this case, methadone or buprenorphine are appropriate alternatives.  The current medical evidence does not support the use of Suboxone MIS Film in this patients case.  Myers and colleagues provide some support for the use of buprenorphine in this clinical setting.  All told, Suboxone MIS Film is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for Vytorin tablets. Based on the records provided, the patient presents with increased coronary risk but no clinical obstructive coronary disease. In this circumstance, guidelines for the evaluation and management of hyperlipidemia are established and endorsed by several national organizations. These guidelines indicate that if the patient is not at goal LDL reduction despite maximal tolerated statin medications, then consideration of adding ezetimibe is reasonable and appropriate. Ezetimibe is the generic equivalent of Zetia and as such should have the same efficacy and side effect profile as Zetia contained within Vytorin. The use of Vytorin is not medically necessary in this case since the available generic equivalent is equally effective. Therefore, the requested Vytorin tablets are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested Vytorin tablets are not medically necessary for the treatment of this patient.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

The patient has requested authorization and coverage for Entresto 24 mg- 26 mg twice daily. The patient has been diagnosed with chronic systolic congestive heart failure, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and hyperlipidemia. Researchers reported sacubitrilvalsartan is an angiotensin receptorneprilysin inhibitor that is indicated for the treatment of patients with symptomatic heart failure with reduced ejection fraction. Entresto could be considered medically necessary in the presence of ongoing New York Heart Association (NYHA) class II-IV heart failure despite standard heart failure medication (diuretics and spironolactone), which this patient is not documented to be taking. In this case, the patient has a history of a reduced left ventricular ejection fraction of 35% and prior congestive heart failure that was not classified. In addition, the reports did not document congestive heart failure symptoms. The medical evidence does not support the requested medication in this clinical setting. Therefore, Entresto 24 mg-26 mg twice daily is not medically necessary for the treatment of this patient. 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 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

A 55-year-old male enrollee has requested a motorized scooter for treatment of multiple sclerosis. The patient has a mobility deficit that is currently accommodated by a four-wheeled walker. The patient does not meet criteria for a scooter/power-operated vehicle. If the patient is limited in his mobility in the home and cannot be accommodated by an alternate gait aid, then a wheelchair should be considered rather than a scooter. Based on the information provided, there is no objective evidence of a need for a motorized scooter.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old female who was found to have a right parietal cystic lesion with multiple septae. She underwent an endoscopic biopsy and decompression in May 2005, which was complicated by a deep white matter infarct leaving her with left hemiparesis.  Her neurological problems are most significant in the left upper extremity. Despite inpatient rehabilitation and outpatient therapy the patient continues to have severe left arm and hand weakness. She is requesting authorization for hyperbaric oxygen therapy for treatment of this condition.  The Health Plan denied her request based upon a determination that the therapy is not medically necessary.Several meta-analyses including a Cochrane Report, have shown there is no clinically significant advantage to hyperbaric oxygen therapy over standard rehabilitative care following a stroke. The efficacy of hyperbaric oxygen therapy has not been established and it is not considered the standard of care within the neurological community.   Hyperbaric oxygen therapy has no role in later-stage rehabilitation of hemiparesis. Therefore, 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: 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 very 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. 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: Upheld

A 20-year-old female has requested residential treatment services for treatment of an eating disorder.  Findings:  The physician reviewer found that it appears there was a clear opportunity to transfer the patient to a higher acuity program. The treatment that occurred during the time period at issue did not change. The documentation does not support a delay in transferring the patient to the acute eating disorder program. The record submitted does not suggest active negotiation or preparation for a seamless transfer during that time, but rather a resistance to transfer to a higher level of care. Continuation of care at the residential treatment level did not meet the medical needs of the patient
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested gastric emptying study, a computed tomography (CT) angiography and a fecal microbiota transplant for treatment of the enrollee, who has a history of abdominal pain.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has symptoms consistent with gastroparesis, but also consistent with other diseases.  Camilleri and colleagues noted since accelerated gastric emptying and functional dyspepsia can also present with symptoms similar to gastroparesis, documentation of delayed gastric emptying is necessary before selecting therapy with prokinetics agents.  The importance of accurate diagnosis is underscored by the fact that other diseases such as chronic gallbladder disease can overlap gastroparesis and dyspepsia symptoms, resulting in unnecessary surgery.  Another potential cause for the patients symptoms, including abdominal pain after eating, is mesenteric ischemia, which presents a diagnostic challenge due to nonspecific symptoms such as abdominal pain and bloating; laboratory tests are neither sensitive nor specific.  Based on the provided information, a gastric emptying study and CT angiography are medically indicated in this case.  However, fecal microbiota transplant is not currently indicated for the patient, as there is a lack of evidence that he has Clostridium difficile infection.  For these reasons, the requested gastric emptying study and CT angiography are medically necessary in this case, but fecal microbiota transplant is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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 parent of a 17-year-old male has requested coverage for partial hospitalization services for 18 days for treatment of the enrollees polysubstance dependence.  Findings:  The physician reviewer found that based on review of the available records, the PHP services provided to this patient on the dates in question are not supported as medically necessary. Applying the treatment guidelines from the American Psychiatric Association (APA), the patients records do not document any risk factors that would require PHP level of care. The patient was cooperative and lived in a supportive family. The provider did not document the presence of any medical or psychiatric co-morbidities, or of any suicidal or homicidal ideation, psychosis, or run away behavior, that would preclude treatment at a lower level of care. Therefore, the services at issue were not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee requested authorization and coverage of oral surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees temporomandibular joint disorder.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural injections (facet injections). Findings:  The physician reviewer found that the American Society of Interventional Pain Physicians (ASIPP) updated recommendations support the clinical utility of the requested cervical facet injections in this patients care. ASIPP noted that, diagnostic cervical facet joint nerve blocks are recommended in patients with somatic or non-radicular neck pain or headache and upper extremity pain, with duration of pain of at least three months, without preponderance of evidence of discogenic pain, disc herniation, or evidence of radiculitis. The ASIPP guidelines also state that once conservative management for cervical facet joint pain has been exhausted, appropriate diagnosis with controlled diagnostic blocks is essential. Following this, therapeutic cervical facet joint interventions may be indicated. In this case, the patient has longstanding neck pain without any significant radiation into the upper extremities for over one year. She has MRI findings of multilevel cervical disc disease as well as listhesis of C3 on C4. There was no report of canal stenosis in the MRI. The patient has tried and failed conservative management with NSAIDs, Norco and a home exercise program. She has reportedly experienced benefit from previous injection therapy. Based on the current guidelines, the requested epidural injections (facet injections) are medically necessary for treatment of this patients neck pain. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 parent of an enrollee has requested reimbursement and prospective authorization and coverage for the continuation of 64.5 hours per month of one-on-one applied behavioral analysis (ABA) therapy and 10.8 hours per month of supervision provided for treatment of autism. Findings: The physician reviewer found that the Health Plan has authorized 43 hours per month (11 hours per week) of one-on-one ABA and eight hours per month of supervision, which is less than what has been provided in the past. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. In this case, the patient continues to demonstrate low to moderately low adaptive skillsets as measured across multiple domains. The patient also requires a high level of support to complete activities of daily living and does not problem solve independently. While the patient has met his behavior goals, he continues to work on communication, daily living, socialization and safety goals. The patient continues to struggle with stopping at the curb and looking both ways before crossing the street and completing purchasing routines. Failure to master these skills puts the patient at an increased risk for injury. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for venous blockage repair with stent placement.  Findings:  Two physician reviewers found that the patient has a history of left symptomatic lower extremity iliac deep vein thrombosis (DVT) during pregnancy. At that time an inferior vena cava (IVC) filter was deployed to prevent embolic disease. An iliofemoral thrombolysis was performed in the left iliac deep vein for DVT.  The records indicated that this procedure was effective.  During the imaging for her IVC filter retrieval, a narrow vein and multiple collaterals were identified suggesting venous stenosis and a possibility of May-Thurner syndrome anatomy with residual scarring from DVT.  The patients veins were opened but stenosed and no acute DVT.  Angioplasty was performed with documented failure due to recoil, so a stent was placed. The procedure at issue was likely to be more effective than other options for the treatment of this patients medical condition.  The current medical literature supports placement of iliac vein stents as effective and a safe approach for patients with post-thrombotic syndrome and non-thrombotic iliac vein lesions with a low incidence of perioperative complications and acceptable long-term patency. The current medical literature indicates that angioplasty has been effective for treatment of May-Thurner syndrome. This patients clinical records noted venous stenosis and a likelihood of May-Thurner syndrome.Final Result: Two reviewers determined that the procedure at issue was likely to be more beneficial for treatment 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 vascular surgery 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: A patient has requested authorization and coverage for bilateral breast revision reduction surgery. Current medical evidence does not support the requested services in this clinical setting. This patient complains of back pain and neck strain. There is no report of chronic breast pain due to weight of the breasts or intertrigo that is unresponsive to medical management. While the patient complains of neck strain, there is no documentation of upper back, neck, or shoulder pain. There is also no report of thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Shoulder grooving is not reported on physical examination and is not visible in photos received for review. Under these circumstances, the requested bilateral breast revision reduction surgery is not medically necessary for treatment of the patients medical condition. Pursuant to California Health & Safety Code  1367.63, every health care service plan contract must cover reconstructive surgery, which is 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 either improve function or to create a normal appearance, to the extent possible. In this case, the requested services do not address an abnormal structure of the body, and the appearance of the patient is normal. There is no documented loss of function. Furthermore, residual breast enlargement that follows breast reduction surgery is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Accordingly, coverage for the requested bilateral breast revision reduction surgery in this case is not required by California Health & Safety Code  1367.63.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. The reviewer also determined that the requested services are not reconstructive surgery, as that term is defined by California Health & Safety Code  1367.63. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery. The reviewer is an expert in the treatment of the patients 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.