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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for bilateral occipital and trigger point nerve blocks. In this case, the patients pain complaints are corroborated by physical examination findings. In addition, the patient has failed a number of conservative measures including physical therapy and medical management. The provider charted the patients improvement in function with prior occipital nerve blocks to substantiate an indication for repeat injection therapy. Furthermore, the literature demonstrates that occipital nerve blocks have been shown to be low risk and efficacious for the treatment of occipital neuralgia. Given these findings, the requested bilateral occipital and trigger point nerve blocks are likely to be more beneficial for the treatment of the patients medication condition than any available standard therapy.One reviewer found that the requested bilateral occipital and trigger point nerve blocks are not likely to be more beneficial for the treatment of the patients medication condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing.  One Reviewer is board certified in anesthesiology with subspecialty certification in pain management 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: The patient has requested authorization and coverage for a PR510 Zero Gravity infinite position MaxiComfort lift chair.Findings:  The physician reviewer found that Chu and colleagues report that despite continued research efforts into this group of genetic neuromuscular disease, patients with limb-girdle muscular dystrophy (LGMD) continue to be treated symptomatically with the aim of prevention or addressing complications. Pousada Garcia and colleagues state, There is a need for a more comprehensive investigation into the role of different kinds of support that can improve the quality of life of persons with neuromuscular disease. In a study on the effects of different assistive seats, Lou and colleagues report that further studies are needed to examine the biomechanical effects of assisted seats on individuals with disabilities.  While the records note that the patient has a neuromuscular disorder and difficulty standing up from a chair, he is able to ambulate once standing. In this case, the requested equipment includes zero gravity, Trendelenburg, and recline positions and settings that exceed the patients medical needs. Given that there is insufficient evidence in current medical literature indicating a medical need for a recliner lift chair for this patients neuromuscular disease, the requested equipment is not medically indicated. Therefore, the requested PR510 Zero Gravity infinite position MaxiComfort lift chair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: 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 the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it gives the radiologist interpreting mammograms especially in cases with extremely or heterogeneously dense tissue.  The advantage relates to the tomographic qualities of the new technique which often allow the reader to separate dense glandular elements from underlying mass/architectural distortion. This results in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) protocol was likely of greater benefit to the patient than had the exam been done with 2D technique alone.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A review of the record indicates that the enrollee presented to an urgent care center. The records noted a two-day intermittent fever, night sweats, and right flank pain. The enrollee was evaluated, laboratory evaluations were completed, and she was discharged home with medication therapy including an antibiotic and an anti-inflammatory. The providers assessment was pyelonephritis with tubule-interstitial nephritis.At issue in this case is whether the enrollee received emergency medical services on the date of service in question. 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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. In addition, California law defines an Emergency medical condition as a medical condition that manifests 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 placement of the patients health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.Urinary tract infection (UTI)/pyelonephritis can be very well treated as an outpatient if a patient is otherwise well (no septic symptoms such as low blood pressure, low oxygen saturation, or sick appearance) and the patient is tolerating by mouth well. In this case, the patient appeared to be tolerating by mouth well, with no vomiting, and she had no septic signs or symptoms. Under these circumstances, the patient did not present with an emergency medical condition that manifested itself by acute symptoms of sufficient severity such that the absence of immediate medical attention would be expected to result in placement of her health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Accordingly, the services provided were not emergency medical services.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 pediatrics, with subspecialty certification in pediatric nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested circumcision for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) recently published a policy statement regarding circumcision in support of the procedure. The AAP has indicated that the benefits outweigh the risk, recommending circumcision for any neonatal infant in whom there are no medical contraindications, and accepting family preference. The Center for Disease Control (CDC) has taken this stance even further, recommending discussion with adolescent and adult men regarding benefits and risks of circumcision surgery. Benefits include prevention of urinary tract infection, acquisition of human immunodeficiency virus (HIV), transmission of some sexually transmitted infections, and penile cancer. Based on these current recommendations, circumcision after the neonatal period is medically necessary and medically appropriate for this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and pediatric critical care 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 38-year-old female enrollee has requested Ampyra, one tablet twice per day for treatment of her multiple sclerosis.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has multiple sclerosis and has been treated with Ampyra.  There has been reported clinical and functional benefit.  Ampyra has been demonstrated to improve walking in patients with multiple sclerosis.  However, the clinical trial measure of improved gait speed is only one of multiple possible indicators of success.  This patient has noted improvement in spasms and fatigue, and has had a documented improvement in gait speed.  The current medical evidence supports the requested medication in this clinical setting.  All told, the requested Ampyra, one tablet twice per day is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee requested community based adult services at the frequency of three times per week for medical treatment of her mental health.  Findings:  The physician reviewer found that according to California Department of Healthcare Services, community based adult services may be considered for patients who are diagnosed by a physician as having an organic, acquired traumatic brain injury and/or have a chronic mental illness; or a medication induced movement disorder; who require a need for assistance or supervision with at least two of the following: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management and hygiene or one of the activities of daily living previously listed and help with money management, accessing resources, meal preparation or transportation.  Although there is documentation showing that the patient has been diagnosed with major depressive disorder, there is a lack of evidence showing that the patient requires assistance with activities of daily living, requires assistance with medication use, or requires assistance in making meals. In addition, the community based adult service assessment provided for review indicates that the patient did not meet the eligibility criteria for community based adult services. Therefore, the request for community based adult services at a frequency of three times per week is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee, with a history of diabetes mellitus, has requested authorization for a continuous glucose monitoring system (Dexcom) and related supplies.  Findings:  The physician reviewer found that real time glucose monitoring systems such as Dexcom system alarm the patient if blood glucose values rise too high or drop too low. It has been shown that these meters also improve overall glucose control. These devices permit patients to evaluate their carbohydrate counting and boluses. They allow for early intervention to prevent rapid rises or drops.  Every sudden change in blood glucose values has to be confirmed by a fingerstick.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl transdermal patch 25 mcg/hr for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The records document that the patient is allergic to morphine. Thus, she cannot use that drug as an alternative to fentanyl.  The Health Plan recommended that there be a plan for tapering the opiates.  However, the Centers for Disease Control and Prevention guidelines do not indicate that all patients need to be tapered off opiates.  In this patients case, the treating provider reported that the current regimen of fentanyl 25 mcg/hr and fentanyl 12 mcg/her enables the patient to perform her activities of daily living.  She is stable on this regimen, and there is no evidence of diversion or abuse. 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 sub-specialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested a phase I clinical trial of high dose immunoablation followed by autologous stem cell transplantation (NU FDA CIDP.AUTO 2003) for the treatment of her chronic inflammatory demyelinating polyneuropathy. Findings:  Three physician reviewers found that although immunoablation followed by stem cell transplantation shows promise as a potential therapy for chronic inflammatory demyelinating polyneuropathy, there currently is not adequate literature to support its use over more standard and tested therapies for this condition. No large scale controlled trial has been performed with a population with this condition. The efficacy and safety has not been determined in a large size, or even moderate size, population with chronic inflammatory demyelinating polyneuropathy.  Furthermore, this patient has not tried more standard and proven therapies for this condition, such as plasma exchange or other immunosuppressive agents such as mycophenolate mofetil and rituximab.  The use of the requested stem cell transplantation in place of these therapies could cost the patient potential benefit at the risk of severe side effects. At this time, stem cell transplantation remains promising. However, until the safety and efficacy can be proven, its use should not supplant more traditional and tested therapies.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eleven-year-old male enrollee has requested acute inpatient mental health services at two facilities and prospective mental health residential treatment center care, status-post discharge from the acute inpatient level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that acute inpatient mental health services provided at the first facility were medically necessary as the medical records indicate the patient was engaging in self-injurious behavior with numerous self-inflicted puncture marks on his arm. In addition, the patient continued to verbalize thoughts of wanting to hurt himself. He has a significant history of mood disturbance, self-harm ideation, impulsivity and aggression. Subsequently, the patient was admitted to an acute inpatient level of care at a second facility three days after his discharge from the initial acute inpatient facility. The submitted records establish the medical necessity of these services. The medical records indicate the patient had thoughts of wanting to cut himself and the patient verbalized thoughts of not liking himself. His history is positive for carrying out self-harm behavior, with impulsive behavior and mood instability. As noted in AACAP practice guidelines, a history of rapid mood shifts, depression and rage are all associated with a high rate of suicide attempts. Given this symptomatology, it is evident that the patient has required an intensity of care only available in an acute inpatient setting. This level of care should continue until it is determined that the patient is stable for step-down to a less intensive level of care. The request for residential treatment center (RTC) level of care post-discharge from acute psychiatric hospitalization is medically necessary and clinically indicated as this proposed level of care is consistent with CALOCUS guidelines and AACAP practice guidelines. CALOCUS recommendations for the RTC level of care include the presence of serious risk of harm, significant impulsivity, and physical aggression with poor judgment and insight. Self-harm ideation, impulsivity, poor judgment and aggression are well-documented in the medical records for this patient. The medical records indicate that the patient has been guarded and not engaged in treatment. The RTC level of care is also indicated when there is serious functional impairment such as impulsive and abusive behavior. The presence of serious functional impairment alone is an indicator for 24-hour services according to CALOCUS criteria. Additionally, this patient has demonstrated significant difficulty in maintaining therapeutic gains and previous treatment has not achieved optimal control of symptoms. There are also co-morbid conditions listed in the medical records which include attention deficit hyperactivity disorder (ADHD), fetal alcohol exposure, post-traumatic stress disorder, and reactive attachment disorder, all of which can significantly impact the course of treatment for his mood disorder diagnosis.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a four-year-old female enrollee has requested The Vest Airway Clearance System (The Vest) for treatment of spinal muscular atrophy type I (SMA I).  Findings:  Two physician reviewers found that good pulmonary care, including chest physiotherapy, is important in maintaining the health and prolonging the life of patients with SMA. Respiratory complications are the primary cause of mortality with this disease. Although there are no controlled studies in the literature to support the use of The Vest in SMA patients, there is certainly anecdotal evidence of its usefulness. It is unlikely that there will ever be a well-designed, controlled study of The Vest in SMA patients because of the relative rarity of the illness and the problems associated with case matching. The usefulness of The Vest for the treatment of cystic fibrosis is well established. Extrapolation to other conditions requiring assisted respiratory clearance such as SMA is reasonable.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested authorization and coverage for LSVT BIG therapy to treat her Parkinson's Disease.  Findings:  The physician reviewer found that LSVT BIG therapy is a technique promoted to improve vocal quality and movement in patients with Parkinsons disease.  It is derived from the Lee Silverman Voice Treatment and focuses on intensive exercising of high-amplitude movements.  Deane and colleagues conducted a review of LSVT compared to standard speech therapy to address dysarthria.  The authors noted that there is insufficient evidence regarding the efficacy of any specific form of speech and language therapy over another for the treatment of dysarthria in Parkinsons disease.  This patient has mild Parkinsons disease, and best practices recognize the value of ongoing physical activity in this and other chronic neurologic conditions.  However, the studies of LSVT BIG are underpowered to demonstrate benefit compared to other physical activities.  All told, the requested LSVT BIG therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision surgery and fusion. Based on the available documentation, including additional medical records, the requested revision surgery and fusion is medically necessary at the L3-4 level, but not medically necessary at the L4-5 level. The postoperative CT has revealed persisting central canal stenosis at L3-4 and severe bilateral foraminal stenosis at the same level. The magnetic resonance imaging (MRI) scan revealed severe central canal stenosis at L3-4 with severe neural foraminal narrowing. There is also grade I anterolisthesis at that level. Based upon this additional information, the request for decompression and fusion at L3-4 is supported as medically necessary. However, the requested exploration and decompression of the L4-5 level is not medically necessary.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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 35-year-old female enrollee has requested for a Paradigm REAL-Time continuous glucose monitoring system (CGMS) for treatment of her type 1 diabetes mellitus.  Findings:  Two physician reviewers found that the CGMS is FDA approved for patients with diabetes mellitus and problems with hypoglycemia and wide fluctuations in blood glucose levels. The scientific evidence supports a decrease in the time spent in hypoglycemic range and probable improvement in Hgb A1c values. The patient already has complications related to her diabetes and the CGMS will enable her to have better glycemic control.