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

The parent of a five-year-old female enrollee requested authorization and coverage of continued speech therapy to lower the risk of choking and aspiration as well as improve nutritional intake and speech.  The health plan denied the enrollees request indicating that continued speech therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested gastric sleeve revision up to the antrum and/or a duodenal switch procedure for treatment of the enrollees medical condition status post sleeve gastrectomy.  Findings:  The physician reviewer found that the records indicate that this patient has current vitamin deficiencies, which would worsen with a duodenal switch procedure, as compliance with follow-up is greater and failure to follow-up is accompanied by more serious consequences. The records provided for review include post-operative dietary visits, but there are no updated behavioral or exercise follow-up information. There is no updated multidisciplinary evaluation regarding her candidacy for a revisional procedure. Given that she has not undergone an updated multidisciplinary evaluation, the medical necessity of any revisional procedure is not established for this patient.
Appeal type: Urgent Care
Decision: Overturned

A 22-year-old female has requested coverage for past emergency services provided.   Findings:  The physician reviewer found that the patient presented to the emergency department with a chief complaint of a sore throat and fever since the previous day. She rated her throat pain as 9 on a scale of 1 to 10. The physician noted the patient had a fever of 102.6 degrees Fahrenheit and a rapid heart rate at 112. Her blood pressure and respiratory rate were normal. Physical examination revealed tonsillar hypertrophy (left side greater than right), tonsillar exudates, and cervical lymphadenopathy. A throat culture was performed, but a rapid strep screen was not obtained. A diagnosis of pharyngitis - strep presumed was made, and the patient was treated in the emergency department with four medications (all given orally): Motrin, Tylenol, Norco, and penicillin. She was discharged from the emergency department with a prescription for penicillin (10-day course) and Norco 5/325 #24 for pain. The patient was instructed to follow-up with her primary care physician in 2-3 days if not better.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.The patients symptoms on the date at issue met prudent layperson criteria for emergency care. The patient had a bacterial infection of her throat with abnormal vital signs (elevated temperature and heart rate) and was documented to be complaining of severe pain (9 out of 10). A prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. All told, an individual in this patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen 10% infusion (HCPCS J1459), 160 units every four weeks.Treatment of severe dermatomyositis must be individualized based on the clinical findings, presentation, and lab values. In particular, severe cutaneous dermatomyositis is not as responsive to prednisone but can be responsive to other systemic agents including methotrexate and IVIG (Cobos, G., et al.). Cobos and colleagues mention that IVIG is quickly started for patients with severe skin disease, and it can help to discontinue immunosuppressive agents such as prednisone or methotrexate.In this case, the patient has documented findings that are consistent with severe skin disease. The patient is currently on methotrexate and prednisone with some improvement. The provider has prescribed IVIG based on the severe cutaneous findings (muscle findings by MRI were found later and prednisone started in response). As methotrexate is immunosuppressive, given the COVID-19 pandemic, it has been associated with increased hospitalization if a patient is infected with COVID-19. Given the prevalence of the omicron variant and breakthrough infections despite vaccination, the provider has noted that it would be prudent to try to decrease methotrexate and prednisone dosing as rapidly as possible as it would be best to avoid agents that increase COVID-19 morbidity. Under these circumstances, the requested medication Privigen 10% infusion (HCPCS J1459), 160 units every four weeks, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with extremely dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional views was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block. Findings:  The physician reviewer found that : The physician reviewer found the current medical evidence has not established the superior efficacy of the services at issue. While occipital nerve blocks have been used for diagnosis of occipital neuralgia, randomized controlled trials are still in process. The literature supporting occipital nerve blocks is mostly anecdotal, open-label and case series reports lacking an active comparator. All told, occipital nerve block was not likely to have been more effective than other treatment options in this patients case. Final Result: Two of the three  reviewers determined that the services at issue were 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 & 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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

A 42-year-old female enrollee has requested azithromycin for the treatment of her Lyme disease. Findings:  The physician reviewer found that the material provided for review does not provide confirmatory evidence that the patient has Lyme disease or any other infection.  There is no indication in the submitted records of when the patient was thought to have been infected. All of the results provided of Western Blots for Borrelia (the definitive test for infection with the organism that causes Lyme disease) have been negative by CDC criteria. Even if the patient had been infected with this organism, she notes that she has previously received doxycycline therapy. It also appears from the submitted records that she has been treated with two antibiotics for about 18 months. Macrolides (the family that includes azithromycin) are not recommended as therapy for treatment of early Lyme disease. Furthermore, azithromycin has a very long half-life that allows five days dosing to yield therapeutic serum levels for about two weeks. Dosing on a daily basis would produce very high serum levels, and as such, could pose a safety risk.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis for treatment of the enrollees lumbosacral spondylosis.Findings:  Three physician reviewers found that the enrollee has a history of knee pain, lumbar radiculopathy, osteoarthritis of the hip, and lumbar disc degeneration. The patient presented to her provider on 2/5/16 and reported pain in the back and upper left leg. The patient described this pain as constant, shooting, worse with activity and better with medications. The pain had begun two months prior to the visit in February. The patient had tried heat, ice, and transcutaneous electrical nerve stimulation. Per the patient, the treatments helped some. Straight leg raise was positive on the left. The patient had pain with extension and flexion of the lumbar spine. A magnetic resonance imaging noted degenerative changes with retrolisthesis and spinal stenosis. On 2/11/16, a lumbar epidural injection was performed. On 3/31/16, the provider notes stated that since the diagnostic facet joint medial branch blocks helped the patients pain more than 80%, he recommended left sided L4, L5, and S1 radiofrequency neurolysis. On 3/31/16, a left sided L4, L5, and S1 radiofrequency neurolysis was performed. The operative report stated the patient responded well to medial branch blocks at L4, L5, and S1. On 4/14/16, a right sided L4, L5, and S1 radiofrequency neurolysis was performed. The operative report stated the patient responded well to medial branch blocks at L4, L5, and S1. The medical literature is clear about how a diagnostic medial branch block should be performed prior to radiofrequency neurolysis, specifically using a pain diary for the day to verify when the local anesthetic wore off. In the documentation available for review, the provider does not document a pain diary for the medial branch block performed prior to the radiofrequency neurolysis. Moreover, radiofrequency neurolysis is not recommended when patients have radicular pain. It was also possible the patient would have had the same relief from a steroid injection alone without having the increased risk from the radiofrequency neurolysis. The submitted records do not mention prior failure from facet injections. Finally, there is no documentation of a home exercise program or physical therapy. Final Result: Three reviewers determined that the services at issue were 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 physician reviewers are board certified in anesthesiology 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 Synvisc injections for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. The use of hyaluronan is not consistently and unambiguously supported by evidence based literature. The basic scientific rationale for hyaluronan effecting arthritis of the knee has not been confirmed. A meta-analysis of the efficacy of viscosupplementation performed by researchers included a total of 89 trials involving 12,667 adults with knee osteoarthritis. The authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. In addition, the American Academy of Orthopaedic Surgeons practices guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. In sum, the request for Synvisc injections to be utilized in the management of the patients osteoarthritis is not medically necessary given the lack of support in the evidence based literature.  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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  Three physician reviewers found that the request for Harvoni is medically necessary and is the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy. Therefore, Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Three reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Decipher prostate test. Findings:  The physician reviewer found that  In this case, a prostate pathology report dated reported a prostate-specific antigen (PSA) level of 5.5 ng/mL, multifocal Gleason 3+3 disease, and high-grade prostate intraepithelial neoplasia (PIN). While the Decipher prostate test may not be indicated for all patients with equivocal prostate pathology results and elevated PSA, it is specifically designed for this diagnostic situation. In this clinical setting, management options included a saturation biopsy or adding genomic information to guide therapy in the face of the patients multifocal disease process.  Therefore, the Decipher prostate test was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Decipher prostate test at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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 was admitted for intensive outpatient program (IOP) services on 10/25/18. His diagnoses included: depressive disorder; oppositional defiant disorder; personal history of self-harm; attention deficit hyperactivity disorder; and cannabis use disorder. The progress notes indicate the patient has made minimal behavioral improvement and has engaged in recent self-harm and substance use. The patient was noted to continue to have stressful relationships due to lack of his ability to follow rules. The progress notes document minimal participation and investment in therapy. The patient continues to have some depression symptoms, substance use, and relationship issues. The progress notes indicate that the patient does treatment activities to appease others. It appears the continued group and individual therapy will be beneficial for the patient. It also appears that continued family therapy is crucial for recovery. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient has composite score of 19, which correlates with a treatment intensity level of three, which is for IOP services. Given this support, the IOP services provided from 1/16/19 forward were and are medically necessary to treat the patients behavioral health conditions.Final Result: The reviewer determined that the requested services 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 psychiatry with subspecialty certification in child and adolescent 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: Overturned

A 50-year-old female enrollee has requested Voltaren 1% gel for the treatment of her bilateral tarsal tunnel syndrome.  Findings:  The physician reviewer found that Voltaren gel is a topical presentation of diclofenac, a nonsteroidal anti-inflammatory drug (NSAID) and is indicated for the relief of osteoarthritis of the joints amenable to topical treatment. Voltarens mechanism of action is related to the inhibition of cyclooxygenase, an enzyme involved in the conversion of arachidonic acid into prostaglandins which are mediators of inflammation and pain. The amount of systemic absorption of Voltaren gel is approximately 6% compared to the serum levels achieved with oral administration of the oral presentation. Although the cardiovascular and gastrointestinal risks are not completely eliminated with Voltaren, the possibility of such side effects is decreased. This particular patient has a history of renal surgery and therefore is at a higher risk of renal complications with oral NSAIDs. As such, the use of Voltaren in this particular setting is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for gastric Lap-band surgery for treatment of her obesity. Findings:  The physician reviewer found that the medical records do not document completion of a multidisciplinary evaluation, including a dietary evaluation, behavioral evaluation, and medical evaluation.  In the absence of this documentation, the medical necessity of the requested procedure cannot be established.  Additionally, failed weight loss efforts should be documented prior to the requested surgery.  All told, the requested gastric Lap-band surgery is not medically indicated for the treatment of this patient at this time.