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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for additional CPT codes L5647, L5781, and L5988 for prosthetic device of the right leg. In this case, the patient has a transtibial amputation and is ready for a definitive prosthesis, given his significant residual limb volume reduction. He has used a preparatory prosthesis for a sufficient period of time. Notably, he is reported to have congestive heart failure with a reduced ejection fracture. A traditional suction socket and suspension system (L5647) with sleeve is appropriate and necessary to maintain adhesion of the definitive prosthesis to the residual limb.  In this patients case, a vertical shock reducing pylon (L5988) is necessary and appropriate to reduce the transmission of ground reactive forces to the residual limb, improving gait and reducing the risk of residual limb soft tissue injury. Active vacuum-assisted suspension systems aim to minimize residual limb volume changes to provide better fit during the day. Authors found that further investigations are needed to evaluate the long-term effects of these systems, and even though suction sockets could create better suspension, fit, and gait performance, overall satisfaction was higher with the pin/lock system. In a study evaluating gait with an active or inactive vacuum suspension system, Researchers found that the differences were small and not considered clinically significant. Therefore, CPT code L5781 is not medically necessary. All told, CPT codes L5647 and L5988 for prosthetic device of the right leg are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are partially medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer 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

A 65-year-old male enrollee has requested for computed tomographic (CT) angiography of the coronary arteries for evaluation of his history of abnormal stress tests.  Findings:  Three physician reviewers found that the peer reviewed evidence does not demonstrate that conventional angiography placed this patient at greater risk. The risk of bleeding is far more likely to occur in an individual with a low platelet count, which this patient did not have. Nor is there convincing evidence suggesting that conventional angiography places a CLL patient at higher risk of infection. Further, the patients reports of abnormal Thallium stress test reports do not appear to have been confirmed prior to the ordering of the CT angiography.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement at C5-6 and C6-7. Davis and colleagues performed a prospective, randomized, controlled multicenter clinical trial on patients with two-level symptomatic degenerative disc disease treated with cervical arthroplasty versus those who underwent two-level anterior cervical discectomy and fusion. The authors reported that their findings supported the use of cervical arthroplasty at two contiguous levels given the advantages over two-level anterior cervical discectomy and fusion. Coric and colleagues reviewed a prospective, randomized, controlled multicenter investigational device exemption clinical trial and concluded that total disc replacement was superior to anterior cervical discectomy and fusion for the treatment of patients with two-level contiguous pathology at five-year follow-up. This patient is being treated for cervical spondylotic radiculopathy with evidence of disc degeneration and stenosis at C5-6 and C6-7. The patients provider has recommended treatment with artificial disc replacement at C5-6 and C6-7. However, the imaging studies, including MRI and x-rays of the cervical spine demonstrated degenerative disc disease at C5-6 and C6-7 without compromise of the neural elements. MRI of the cervical spine was reviewed, including the amendment. The findings state no change. There is evidence of a previous anterior fusion at C4-5 and the imaging states the fusion is solid without evidence of any hardware or graft complications. There is limited evidence for any nerve impingement to support the need for the requested artificial disc replacement procedure. Additionally, there is limited published, large-scale, long-term peer-reviewed medical literature that shows artificial disc replacement next to a previously fused level to be an effective and safe treatment. Therefore, the requested artificial disc replacement at C5-6 and C6-7 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: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested a CT angiography (CTA) for evaluation of coronary artery disease (CAD).  Findings:  Two physician reviewers found that CT angiography is not, thus far, a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CT angiography cannot accurately confirm or exclude important coronary artery obstructions. The use of CTA in the diagnosis and prognosis of coronary disease in this subset of patients remains an experimental/investigational application of this technology.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old female with multiple sclerosis who has developed a progressive gait disorder with scissoring. She has been able to ambulate 100-200 feet with a cane and 300 feet with crutches. The patient appears to be able to ambulate with assistive devices for household distances. She has requested authorization for a wheelchair for community mobility purposes. The Health Plan has determined a wheelchair is not medically necessary for the patients mobility.The patient does not meet nationally accepted medical necessity criteria for authorization of a wheelchair. The patient is not bed or chair confined. The submitted information indicates the patient is able to ambulate with assistive devices in her home. While it is probable based upon the patients diagnosis that she will eventually require a wheelchair for home mobility, such need has not been demonstrated at this time. Therefore, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that the patient has history of right knee osteoarthritis who is requesting reimbursement for Orthovisc injections. In the medical literature, researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. All treatments except acetaminophen showed clinically significant improvement from baseline pain. In addition, another research reported that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis, which failed conservative treatment, was efficacious during a 54-month follow-up period. This patient presented with a history of recurrent right knee pain with associated swelling and a diagnosis of right knee osteoarthritis. She was status post Orthovisc injections and a corticosteroid injection, with reported significant pain relief. She had minimal relief reported with Naprosyn. She subsequently underwent Orthovisc injections and steroids to the right knee. There is a lack of evidence that this patient achieved objective improvement with the Orthovisc injections for at least six months, or had failed to respond to corticosteroid injections to support the medical necessity of repeat injections. Although the patient reported pain relief, there were no improvements in right knee range of motion. The combination of the steroid injection and Orthovisc injection given on the same date makes it difficult to determine which injection provided pain relief. All told, the Orthovisc injections they received were not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested service was 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX Reflux Management System. Findings:  The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment, surgical fundoplication. For these reasons, LINX Reflux Management System is not likely to be of greater benefit than the available standard treatment options for the treatment of this patients medical condition. Final Result: Two of the reviewers determined 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services rendered on 4/06/18, 4/11/18, 4/12/18 and 4/16/18, as defined in the Health and Safety Code section 1317.1, subdivision (a)(1). Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on 4/11/18, 4/12/18, and 4/16/18. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.The chiropractic services on 4/06/18, 4/11/18, 4/12/18 and 4/16/18 were not necessary for treatment of an emergency medical condition. The submitted medical records did not include any evidence suggesting an emergency condition or treatment. The treating chiropractors notes classify the patients diagnosis as low to moderate severity condition with a good prognosis and moderate pain. Therefore, the chiropractic services rendered on 4/06/18, 4/11/18, 4/12/18 and 4/16/18 are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in chiropractic medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female enrollee with a body mass index (BMI) of 38. In addition, the patient has comorbid conditions including sleep apnea, hypertension, and degenerative disc disease. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. The patient wishes to undergo gastric bypass surgery. With a BMI of 38 and documented comorbidities including significant sleep apnea and hypertension, gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for shoe inserts (custom molded orthotics). The submitted documentation fails to demonstrate the medical necessity of the requested equipment. Walther and colleagues noted that supportive orthotics are superior to non-supportive orthotics regarding pain reduction in treatment of plantar fasciitis. This patient has been diagnosed with plantar fasciitis bilaterally, metatarsalgia bilaterally, pes planus foot structure with overpronation, and posterior tibial tendon dysfunction. Orthotics may be utilized to treat these ailments. However, the progress notes do not support the need for custom orthotics in this patients case, as there is no physical examination discussing type of heel pain, exact location of heel pain, or any forefoot pain. The records do not support the requested equipment in this clinical setting. Therefore, the requested shoe inserts (custom molded orthotics) are not medically necessary.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. Findings: The guidelines of care for patients with eczema include treatment with measures such as avoidance of triggers, emollients and treatment of superficial colonization or infection of the skin. First-line topical calcineurin inhibitors, UVB phototherapy, and topical corticosteroids have also been shown to be effective. In this case, the patient does not have documentation of failure of the recommended first-line treatment options to support an indication for Dupixent. Specifically, the records do not document that the patient has received adequate treatment with topical calcineurin inhibitors like tacrolimus or pimecrolimus. Given the limited body surface area affected, the patient should receive treatment with these topical agents prior to starting systemic treatment with a biologic like Dupixent. Given these findings, the requested Dupixent is not medically necessary for 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 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: A patient has requested authorization and coverage for transcatheter mitral valve leaflet repair, using the MitraClip Delivery System. Transcutaneous mitral valve repair is supported for patients with: chronic moderate-to-severe or severe mitral regurgitation; severely symptomatic heart failure despite medical therapy; favorable anatomy for the repair procedure; reasonable life expectancy; and prohibitive surgical risk due to comorbidities. This patient presents with a history of cardiomyopathy with severe mitral regurgitation and prior history of stroke radiation pneumonitis and fibrosis. The patient was not found to be a good candidate for surgery given her comorbid conditions. Due to her symptomatic mitral regurgitation and contraindication to open surgery, it is reasonable to repair the mitral valve percutaneously. Therefore, the transcatheter mitral valve leaflet repair, using the MitraClip Delivery System is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the transcatheter mitral valve leaflet repair, using the MitraClip Delivery System is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the transcatheter mitral valve leaflet repair, using the MitraClip Delivery System is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in surgery with subspecialty certification in thoracic surgery and is actively practicing. Physician reviewer 2 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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: Upheld

A 54-year-old female enrollee has requested for thighplasty surgery for treatment of her excessive skin. Findings:  The physician reviewer found that the patients condition does not meet the American Society of Plastic Surgeons (ASPS) criteria for third party coverage of skin resection following massive weight loss. According to the ASPS Position Paper cited above, when surgery to remove extensive skin redundancy is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. Only in rare circumstances will buttock or thigh lifts be needed to treat functional abnormalities.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested treatment in an intensive outpatient eating disorder program for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient continued to experience various symptoms associated with multiple psychiatric diagnoses during the period at issue. However, the patients eating disordered behavior had significantly improved by the end of her participation in partial hospitalization. The cluster of symptoms she experienced during the period at issue would have been more appropriately treated outside of a IOP program that focused on her eating disorder per se. According to the American Psychiatric Association criteria for intensive outpatient eating disorder programs, additional psychiatric problems complicate eating disorders and coexisting psychiatric issues may require treatment at a different level of care. Based on the presence of comorbid psychiatric conditions as well as the fact that the patient had experienced significant improvement in her eating disorder, she did not meet clinical indications for the intensive outpatient eating disorder services at issue.
Appeal type: Urgent Care
Decision: Overturned

A 30-year-old male enrollee has requested an emergency room visit for the treatment of his abdominal pain, blood in his stool and diarrhea. Findings:  The physician reviewer found that the patient's abdominal pain and other physical findings were deemed severe enough to require blood work, urinalysis, and a CT scan while in the emergency department. The examining physician was concerned that the patient might be suffering from appendicitis, which is a potentially life-threatening disorder. It is entirely reasonable and appropriate that the patient sought immediate medical attention for his complaints of abdominal pain, blood in his stool and diarrhea.