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

A 36-year-old female enrollee has requested duodenal switch bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity for the requested procedure. Bariatric surgery is indicated for patients with a BMI of 40 or above, or a BMI of at least 35 with severe co-morbid conditions. This is part of standard guidelines such as the National Institutes of Health (NIH) consensus guidelines for bariatric surgery. Although this patient is an adult that is morbidly obese with a BMI that is greater than 40, the medical necessity for duodenal switch is not determined at this time for failure to document a dietary evaluation and a behavioral evaluation which is part of a standard multidisciplinary evaluation. Thus, the request for duodenal switch bariatric surgery is not clinically indicated at this time. All told, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Remicade infusion 5 mg/kg, three times per week for eight weeks for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that current medical literature supports the requested medication in this clinical case. The diagnosis of Crohns disease has been established in this case by colonoscopy and biopsy results showing ileal disease. The patient also reported consistent clinical symptoms given rectal bleeding for two years and severe bloody diarrhea.  Based on this patients records, this patient has moderate to severe Crohns disease due to severity of symptoms. The American Gastroenterological Association guidelines for induction of remission in moderate to severe disease recommend anti-tumor necrosis factor (TNF) antibodies including Remicade. For maintenance of remission, TNF inhibitors are recommended by these guidelines. These recommendations are corroborated by the American Gastroenterological Association Guidelines for Initial Medical Treatment in Crohns Disease. Uncontrolled disease flares can rapidly result in complications, such as abscess and bowel obstruction, and over time can result in complications such as fistula, stricture, and the need for hospitalization and surgery. The medical literature supports immediate treatment to establish remission and avert complications of Crohns disease, such as stricture, fistula, and dysplasia leading to colorectal cancer.  Additionally, Remicade and the requested dosage is the recommended dosing by the U.S. Food and Drug Administration.  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: Medical Necessity
Decision: Overturned

The mother of an eight-year-old male enrollee has requested a 3-wheeled power scooter for him for the treatment of the enrollees metaphyseal chondrodysplasia. Findings:  The physician reviewer found that mobility needs at this patients age are considerably different from those of other, older patients.  This pediatric patients mobility is significantly impaired due to his congenital disorder.  From the available records, it appears that the patient will be able to operate a power scooter and would not be able to utilize a manual wheelchair for the distances required.  The patients condition and physical limitations demonstrates the indicated medical need for the requested equipment.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 9-year-old enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. The patient has longstanding behavioral problems and was re-admitted to inpatient level of care because of severe aggression which occurred during treatment at the PHP level of care. Per review of the medical records, the patient did not show suicidal/homicidal/psychotic ideation. Although the patient is transgender, there is no evidence in the records provided that the patients behavioral difficulties were secondary to the patients gender identity disorder. While the patient had difficulty with impulsivity and emotional dysregulation, this behavior appeared to be consistent with the patients baseline functioning based on the history obtained from the parents. The patient became more cooperative with staff and psychological testing, with utilization of behavioral interventions. The patient tolerated changes in the medication regimen without difficulty.  No medical comorbidities were noted. The patients activities of daily living were described as adequate. Thus, the documentation submitted for review does not demonstrate a need for 24-hour level of care during the period at issue. The patient could have received further medication adjustments and continued behavioral therapy at a less intensive level of care. Therefore, based upon the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested an out-of-network specialist referral for the treatment of his bilateral lower extremity pain. Findings:  The physician reviewer found that this patient went to his primary care physician with complaints of right foot pain for the prior eight weeks. A tender Achilles tendon insertion was noted, and a diagnosis of Achilles tendonitis was made. An EBoot was dispensed. The boot did not help, and pain was noted in the right and left posterior heels. The patient saw a podiatrist who diagnosed the patient with bursitis ankle/foot, Achilles tendonitis and equinus. The patient was prescribed physical therapy. The patient saw a neurologist for weakness in the legs, and an MRI was ordered. The patient saw another physician, and x-rays revealed tiny spur posterior heel. He reported that Vicodin was not working for the pain. The patient had a neurology follow-up, and foot pain was determined to be unlikely secondary to radiculopathy. The patient had another podiatry visit and an MRI revealed chronic Achilles tendonitis with acute insertional tendonitis. Most, if not all, of the physicians recommend ice, rest, physical therapy, immobilization/stretching boot, orthotics and heel lifts. He has had an MRI and neurology consult. An out-of-network referral is not medically indicated as the patient has had an extensive work-up with concurring recommendations within the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 50 mg Extended Release tablets. Findings:  The physician reviewer found that guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. In this case, the patient has chronic low back pain due to lumbar spondylosis. The provider charted that the patient has been able to successfully manage her pain with a combination of long- and short-acting Nucynta. The patient reported increased back and neck pain and she requested an adjustment to a long-acting medication. The records document that the patient has been participating in a multimodal treatment plan including interventional therapy, most recently, with lumbar facet injections in November 2020. The provider reported that the patient has been able to perform the activities of daily living and function with her current medication regimen of Nucynta ER and immediate release. On 1/14/21, the provider noted that that patients CURES reports and urinalysis have been consistent with her therapeutic regimen. In addition, there is no indication that the patient has demonstrated aberrant behavior. Based on these findings, treatment with Nucynta is consistent with the CDC guidelines as part of a multimodal treatment plan including pain management procedures. All told, the requested Nucynta 50 mg Extended Release tablets are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance-guided high intensity focused ultrasound (MRgHIFU). Findings:  The physician reviewer found that MRgHIFU is a totally noninvasive procedure that has shown promising results in the management of numerous malignant and nonmalignant conditions including desmoid tumors. Griffen and colleagues report that MRgHIFU is ideally suited for the treatment of extra-abdominal desmoid fibromatosis due to its noninvasiveness, lack of ionizing radiation, low morbidity, and good safety profile over conventional treatments including surgery, radiation, and chemotherapy, which may carry significant morbidity. In this clinical setting, MRgHIFU is associated with high rates of local tumor control and expected to reduce the rate of acute and chronic morbidity as compared to other standard management options such as surgery or radiation. Therefore, MRgHIFU is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MRgHIFU is 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 service is 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: Physician reviewers 1 and 2 are board certified in radiation oncology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology 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: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested hernia surgery for treatment of his bilateral inguinal hernias. Findings:  The physician reviewer found that symptomatic hernias should be repaired, unless the patient cannot safely received anesthesia. The natural history of hernias is that they continue to grow, and whether they are symptomatic or asymptomatic can be subjective. Once a hernia is diagnosed, it should generally be repaired, unless the anesthesia risks outweigh the benefits.  This is due to the risk of incarceration and/or strangulation due to untreated hernias. As noted by Fitzgibbons and colleagues, if a hernia is completely asymptomatic, watchful waiting is reasonable.  Bax and colleagues noted that a decrease in surgical repair of inguinal hernias may lead to an increase in hospitalizations related to incarceration or strangulation. In this patients case, although he initially was asymptomatic, he is now complaining of pain.  Thus, the requested hernia surgery is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) mental health treatment  for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that the documentation does not support the medical necessity for the services at issue in this clinical setting. This patient had no post-acute withdrawal symptoms. She was not a danger to herself or others. She was medically stable. Moreover, her psychotropic medications did not require PHP level of care for management. She was not manic or psychotic. She was actively engaged in her treatment plan, and awaiting anticraving medication. She was motivated for recovery and future oriented. Her family was supportive. She had an extensive treatment at intensive outpatient program (IOP) from April 2016 through her admission at the end of November 2016, which amounted to approximately six months. The services at the IOP level of care would have given her a strong educational platform from which to build her coping skills and relapse prevention. Although, the patient continued to struggle with her emotions and presented a risk for relapse, treatment to help her further develop coping skills could have been accomplished at a lower level of care such as resumption of IOP services. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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

A 38-year-old male enrollee requested authorization and coverage of Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the Afirma gene expression testing. The Bethesda System recommends a diagnostic hemithyroidectomy for this type of nodule. The recent American Thyroid Association guidelines state that for nodules with atypical of undetermined significance cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If the genetic test is suspicious, the risk of malignancy increases to 40% and the risk of malignancy decreases to less than 6% with benign findings. In this case, the result of the Afirma gene expression testing was suspicious for malignancy. This increases the patients risk of malignancy to 40%. This information was important to determine whether to perform thyroidectomy, and if so, the extent of surgery. For these reasons, Afirma gene expression testing was 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 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:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the gene testing. The Guardant360 assay is a cell free DNA assay performed on an individual patients plasma. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Guardant360 assay adds to decision making ability, or yields a result that is clinically beneficial. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the gene testing was 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 certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Urgent Care
Decision: Overturned

The parent of a then three-year-old female has requested coverage for past emergency services. Findings:  The physician reviewer found that the patient was brought to the emergency department with complaints of cough and congestion for several days and acute onset of right ear pain one hour prior to arrival. Vital signs in the emergency department included temperature 99.2 degrees, respiratory rate 32, heart rate 108, and oxygen saturation of 100%. Upon examination, the provider noted evidence of otitis media, right with dull, red, thickened, bulging tympanic membrane; left tympanic membrane was normal. The patient was diagnosed with acute upper respiratory infection and otitis media and was treated with antibiotics.  At issue in this case is whether a prudent layperson would have sought immediate medical attention for the patient on 3/31/12. 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.Upon review of the submitted documentation, a prudent layperson would have sought immediate medical attention on the date of service in question. While the submitted emergency department records do not document the patients pain level, the patients parent reports the patient experienced acute onset of severe ear pain an hour prior to presentation, which prompted the family to seek emergency room services. As the above cited statute indicates, the presence of severe pain is an appropriate indication for seeking immediate medical attention. In this case, the patients acute symptoms of severe ear pain were of sufficient severity that absence of immediate medical attention could reasonably be expected to result in continued severe pain and possible impairment of bodily functions (hearing). As such, the patient met prudent layperson criteria for emergency services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nourish formula. Dodrill and Gosa note that swallowing difficulties in pediatric populations can have a detrimental effect on dietary intake and, thus, growth and development. In this case, the patient depends on gastrostomy tube feedings for nutrition and fluid requirements. She has tried and failed multiple formulas, including Pediasure and Pediasure with fiber. The records show she has tolerated Nourish formula. Given that continued use of Nourish formula prevents malnutrition and unwanted side effects, it is medically indicated for this patient. Therefore, Nourish formula is medically necessary to promote physical and mental health and efficiency for this patient.Final Result: The reviewer determined that the requested formula 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 pediatrics with sub-specialty certification in pediatric critical care 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.