Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for food tolerance induction program (TIP) services. The records provided for review document that this patient has a history of food allergies. The patient has been started on treatment with a tolerance induction program (TIP). Oral food challenges and oral food desensitization programs are offered by a multitude of providers. The standard of care in this clinical setting includes measurement of IgE levels to specific foods for an individual patient. However, an extensive array of blood tests and oral desensitization to a multitude of foods in the absence of a history of anaphylaxis is not supported by the peer-reviewed medical literature or clinical guidelines. Furthermore, there is a lack of evidence in favor of oral dosing protocols for foods that are considered intolerances or IgE-mediated allergies. For these reasons, food TIP services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in allergy and immunology and rheumatology and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing. The American College of Cardiology Foundation (ACCF) guidelines do not support use of the advanced lipid testing. Rather, the ACCF guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. The guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. These guidelines are formulated based on thorough review of current literature, and are vetted in a group of cardiology experts before publication. Therefore, the advanced lipoprotein testing 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultra-lightweight titanium frame wheelchair, TiLite Aero Z (K0005), upgraded titanium frame (K0108), litespeed aluminum wheels (K0108), TiLite SlipStream Single Sided Fork (K0108), anti-tippers (E0971), adjustable skin protection seat cushion (E2622), positioning back cushion (E2620), side guards (E0956, E1028), and leg straps (K0038) for treatment of the enrollees paraplegia. Findings:  The physician reviewer found that the available records do not provide detailed documentation related to the patients physical examination, particularly with respect to his neurological, musculoskeletal or functional examinations.  There is only one physical examination provided for review, which noted that the patient was propelling himself in a wheelchair, with no further pertinent documented findings.  There was no documentation related to an examination of the patients wheelchair.  The seating and mobility evaluation at a medical supply vendor was replete with errors, including the patients gender and neurogenic bladder management method.  There was a lack of documentation regarding specifics about the patients current wheelchair. There is, overall, insufficient, conflicting and inaccurate information in the documentation available for review.  The data presented are insufficient to establish the medical necessity of an ultralight manual wheelchair with the requested componentry/accessories at this time.  A wheelchair prescription should include documentation of an appropriately detailed pertinent physical examination, detailed functional evaluation, and a clear and comprehensive discussion of the patients current durable medical equipment if replacement equipment is being requested.  All told, the requested ultra-lightweight titanium frame wheelchair, TiLite Aero Z (K0005), upgraded titanium frame (K0108), litespeed aluminum wheels (K0108), TiLite SlipStream Single Sided Fork (K0108), anti-tippers (E0971), adjustable skin protection seat cushion (E2622), positioning back cushion (E2620), side guards (E0956, E1028), and leg straps (K0038) are not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Nutropin AQ Nuspin Pen Injector. This patient is being treated with a combination of growth hormone and Supprelin to optimize her height potential while suppressing puberty. However, her height has levelled off and she has not grown in stature for over one year. Her bone age of 15 years is consistent with fused epiphyses. She has no known diagnosis of hypopituitarism and no known morphological abnormalities of her pituitary gland. Continuation of growth hormone therapy is not indicated as it will not improve the patients growth once epiphyses are fused. There is no information to support that there is a morphological abnormality of the pituitary gland or evidence of hypopituitarism. Thus, the requested Nutropin AQ Nuspin pen injector is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Nutropin AQ Nuspin pen injector is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in pediatrics with subspecialty certification in pediatric endocrinology 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 an occipital nerve block (CPT codes 64450, 64405). The International Headache Society (IHS) defines occipital neuralgia as a paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution of the greater, lesser and/or third occipital nerves, along with tenderness to palpation over the affected nerve, with temporary pain relief after an anesthetic block required to meet criteria. The HIS notes that pain may be unilateral or bilateral with radiation into the temple or even behind the eye commonly triggered by head movements. In a prospective analysis of 44 patients with occipital neuralgia treated with an occipital nerve block procedure, Jukys and ustickas noted that 95.45% (or 42 patients) showed satisfactory results for at least six months, with decreases in mean headache Visual Analog Scale (VAS). The authors concluded that occipital nerve block provides a safe, technically simple, and effective method that carries a minimal risk of side effects and can be applied for patients that do not achieve desired pain relief using conventional pain management methods. In a randomized, multicenter, double-blind, and placebo-controlled study of 84 patients, Inan and colleagues found that greater occipital nerve blockade with bupivacaine was superior to placebo and was found to be effective, safe, and cost-effective for the treatment of chronic migraines. In this case, the patient has diagnoses of chronic migraines and occipital neuralgia intractable to abortive and prophylactic treatments. Given that current medical literature supports the use of occipital nerve block therapy in decreasing the frequency and severity of migraine headaches, the requested service is medically indicated. Therefore, an occipital nerve block (CPT codes 64450, 64405) 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 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: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee requested authorization and coverage of the prescription medication remicade (Injectable) for the treatment of recurrent idiopathic pericarditis.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the prescription medication remicade (Injectable) is not likely to be more beneficial for treatment of the enrollees recurrent idiopathic pericarditis than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dissection and fusion of the cervical area and lumbar area of the spine, specifically at C5-C7 and L4-L5 and L5-S1. In this case, the records document several recommendations against the requested service by neurosurgery. Despite being requested, the submitted records did not include support from a spine surgeon or neurosurgeon for the requested service. In this clinical setting, given that the records do not support the requested service and document that the patients providers are advising against surgery, the requested service is not medically indicated. Therefore, dissection and fusion of the cervical area and lumbar area of the spine, specifically at C5-C7 and L4-L5 and L5-S1, is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested radiofrequency neurolysis for treatment of her medical condition. Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In this patients case, there is a lack of documentation of a quantified result of the positive diagnostic medial branch block for the requested treatment levels. Additionally, the medical records noted degenerative scoliosis with L2-3, L3-4 degenerative disc disease and lateral listhesis.  However, there were no pathological findings noted for the sacroiliac joint.  There is a lack of support for the requested services in this clinical setting.  All told, the requested radiofrequency neurolysis is not likely to be of greater benefit than other treatment options.  Final Result:  Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left knee arthroscopy. The records provided for review document that this patient has magnetic resonance imaging (MRI) evidence of advanced tricompartmental osteoarthritis of the left knee, full thickness chondral loss of the medial compartment, and a likely degenerative tear of the body of the medial meniscus, which is not displaced. There is evidence of tricompartmental osteophytosis. The provider has recommended arthroscopy. A review of the current medical literature pertaining to arthroscopic debridement of osteoarthritis of the knee reveals mixed findings. Researchers noted that, Over the long-term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function. The authors concluded that of the 13 randomized controlled trials and 12 observational studies assessed, the pain relief post knee arthroscopy is small and short-lived. Researches reported that knee arthroscopy for patients with degenerative knee is limited in time and absent at one to two years after surgery. For these reasons, the requested left knee arthroscopy is 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 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: Overturned

A 60-year-old female enrollee has requested for Euflexxa injections for treatment of her right knee arthralgia secondary to osteoarthritis. Findings:  The physician reviewer found that the patient is unable to tolerate anti-inflammatory agents due to gastroesophageal disease. A cortisone injection provided no significant benefit.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested abdominoplasty/diastasis recti repair to be performed at the same time as a ventral hernia repair for the treatment of her medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested abdominoplasty/diastasis recti repair.  In this patients case, the records document an umbilical hernia and diastasis recti.  The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty.  Coriddi and colleagues evaluated functional status following abdominoplasty and noted that rectus plication did not significantly improve functional outcomes.  This patient does have an umbilical hernia, and the Health Plan has approved coverage for hernia repair.  The hernia repair is medically necessary, as this has the potential to become incarcerated and could present a medical urgency or emergency.  However, there is a lack of evidence indicating that repair of diastasis recti can enhance an umbilical hernia repair.  The photograph provided does not support that this is a severe condition related to the rectus diastasis.   In addition, there does not appear to be a significant pannus to suggest that there is a functional deficit related to this, such as chronic intertrigo, ulcerations and/or lower back pain related to the size of an overhanging pannus. Thus, the requested abdominoplasty/diastasis recti repair is not medically indicated for the treatment of this patient. Final Result:  The reviewer determined that the requested services are not reconstructive in nature 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 plastic surgery and is actively practicing. The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested computed tomography angiography (CTA) for the evaluation of her chest pain. Findings:  Three physician reviewers found that the patient has known coronary artery disease, atypical chest discomfort and an adequate stress echocardiogram that revealed no evidence of provocable ischemia. In this circumstance, continued aggressive risk factor modification is the best approach. A coronary CTA, regardless of the results, would not prompt a treatment change in this setting. Appropriateness criteria for coronary CTA do not recommend performing the test in this circumstance of known coronary artery disease and a recent normal stress echocardiogram.
Appeal type: Urgent Care
Decision: Upheld

A 37-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patient had swelling and pain in his calf for one week prior and had no chronic medical conditions.  The patient was in no acute distress according to the Emergency Department records.  Vital signs and pulse oximetry were normal on arrival. The patient did not have any concerning signs, such as loss of sensation, deformity, dislocation, absence of pulse, bleeding or fever.  The patient had a basic muscle/tendon tear.  The patient had previously been evaluated by his family physician.  The patients symptoms on the date in question did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested speech therapy and occupational therapy for treatment of the enrollees global developmental delays. Findings:  The physician reviewer found that based on the speech and language therapist evaluation, this patient has speech and language deficits related to the developmental delays associated with a chromosomal abnormality. The speech therapist noted delays in both speech and language which she considered developmental in nature. Per Nelson and colleagues, there is a lack of evidence supporting the effectiveness of early intervention for speech and language delay in this clinical scenario.  Given the lack of literature support demonstrating the benefits of speech therapy in this patient population, the requested speech therapy is not medically necessary. With regard to the request for occupational therapy, this patient does have feeding difficulties. Up to 80% of developmentally delayed children experience feeding difficulties. This is considered a medical issue. Consequences can be significant, including failure to thrive and susceptibility to chronic illness. Occupational therapy for feeding delays is considered standard of care for patients with documented swallowing difficulty, such as this patient. Therefore, occupational therapy for these feeding difficulties is medically necessary.