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

The parents of a nine-year-old female enrollee who suffers from cerebral palsy and spastic quadriplegia requested authorization and coverage for an ultra-lightweight wheelchair .  The health plan has denied this request indicating that the requested wheelchair is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee requested authorization and coverage of intensity modulated radiation therapy (IMRT). The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a cold therapy unit. This patient underwent spinal surgery and was provided with post-operative use of a cold therapy unit. Although post-operative dynamic cold therapy units have been proposed as a method of reducing pain and the inflammatory response in the early post-operative period after orthopedic joint reconstruction surgery, there are limited data available showing patient outcomes are improved beyond results experienced with standard ice packs. Cooling devices to achieve relief of underlying back pain is limited at best. Nabiyev and colleagues concluded that when compared to treatment with narcotic pain medications alone, cold therapy units can provide accelerated improvement during early rehabilitation. However, the study did not compare cold therapy units against use of standard ice packs in this clinical setting. All told, the cold therapy unit (CPT code E0218) and related accessory (lumbar wrap, CPT code E1399) provided was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the cold therapy unit (CPT code E0218) and related accessory (lumbar wrap, CPT code E1399) provided was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the cold therapy unit (CPT code E0218) and related accessory (lumbar wrap, CPT code E1399) provided was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurological surgery 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 61-year-old male enrollee has requested multi-agent chemotherapy regimen of 5-FU, leucovorin, Erbitux, Camptosar, Avastin and oxaliplatin for the treatment of his colon cancer metastatic to liver. Findings:  The physician reviewer found that the patients current regimen, including 5-FU, leucovorin, Avastin, Erbitux, oxaliplatin and Camptosar, is a regimen with no clinical evidence to support its use. Though each of these drugs is approved in certain combinations and situations in metastatic colon cancer, using all of them together is rather unprecedented. There is no clinical trial suggesting improved efficacy with this combination. Unfortunately, his cancer is progressing. The usual recommendation in such a circumstance is to recommend a different protocol. There is little basis to say that this current regimen is slowing the progression of disease. This combination is, at best, investigational, of no proven benefit in this situation and not medically necessary.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A request for reimbursement was received for psychiatric emergency medical services per air ambulance that was provided from a medical center to an acute center for eating disorders. The Health Plan has denied the request indicating that the enrollee did not receive psychiatric emergency medical services. The records documented a history of hospital admission for diagnoses including anorexia nervosa, severe hypokalemia and severe protein malnutrition.  The enrollee was transported from inpatient care for urgent impatient medical admission later. Documentation shows the patients severe protein malnutrition, refeeding syndrome, and Wernickes encephalopathy had resolved at the time transport was planned. The patients electrocardiogram (EKG) was normal and vital signs were stabilized. The patient's laboratory values had all normalized and there was no evidence that this patient was grossly orthostatic. The patient did not meet the standard definition of urgency or emergency risk involved in transportation. There was no evidence that a psychiatric emergency condition would exist during transport that would make it necessary to transport the patient via air ambulance. Psychiatrically, the patient did not express suicidal or homicidal ideation, was not self-harming, and was not gravely disabled. There was no documentation that the patient was subject to falls on standard commercial transport that could not be adequately managed by a non-skilled companion travelling with them on a standard airline.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 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

The parents of a six-year-old female with a diagnosis of attention deficit hyperactivity disorder are requesting occupational therapy.  Reviewers Findings:  The reviewing physician found that the relevant medical literature reveals no scientific evidence that sensory integration therapy is beneficial in attention deficit disorder.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 36-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 sore throat. The patient also felt as though her throat was swollen. She reported excessive sweating and difficulty breathing when she awoke in the middle of the night and therefore decided to go to the emergency room. In the emergency department, her vital signs were normal. The severity of the patients pain was documented as moderate. The patient was not short of breath while in the emergency department. Throat examination was significant for uvular swelling and swelling of both tonsillar pillars. A lateral neck x-ray was performed to assess the degree of soft tissue swelling and to rule out epiglottitis. The patient was diagnosed with acute pharyngitis and administered prednisone (most likely to reduce throat swelling) and amoxicillin in the emergency department. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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 due to the severity of pain as well as the symptoms of throat swelling and difficulty breathing when she awoke in the middle of the night. These symptoms may be presenting symptoms of potentially life threatening disorders including epiglottitis, tonsillar abscess and other causes of throat swelling which may compromise the airway. Thus, the absence of immediate medical attention could reasonably be expected to place the patients health in serious jeopardy. Accordingly, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee requested authorization and coverage of a pain pump. The Health Plan denied the request indicating that the requested treatment is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cochlear auditory implant for treatment of the enrollees hearing loss. Findings:  The physician reviewer found that bone conduction hearing aids have been traditionally used for conductive hearing losses. However, expanded indications for Bone Anchored Hearing Aid (BAHA) implantations are developing for sensorineural hearing loss as well. Single-sided deafness (SSD) from pathology, such as acoustic neuromas, or sudden sensorineural hearing loss are recent rationales made for bone conduction aids. Reported benefits for SSD patients include better sound localization and better sound clarity. Classic thinking has been that bone stimulates both cochlea simultaneously. If one cochlea does not work, it seems that the functioning cochlea would be fully stimulated or perhaps even overstimulated before effects are seen on the deaf side. Moreover, BAHA is approved by the U.S. Food Drug and Administration for conductive hearing losses and for single-sided sensorineural deafness. Recent reports indicate that persons who hear in only one ear can achieve improved sound localization and clarity of sound using BAHA on the same side of the skull as the hearing loss. In this patient, who is diagnosed with unilateral profound sensorineural hearing loss, BAHA implantation is medically necessary. Therefore, the requested cochlear auditory implant is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 otolaryngology 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 case concerns a 10-year-old male with short stature.  He fell off of the growth curve at the age of four years and at seven years he had a workup that revealed low GH dependent IGF-1 and IGFBP-3 levels together with a small pituitary on MRI of the brain. At the age of seven, the patients bone age was read as being retarded by approximately 1.5 years and his predicted adult height was close to the target height estimated from parental heights. At age nine, the patient had a GH stimulation series and passed one of the two tests given but failed the other. His bone age was no longer retarded and according to my calculations, his predicted adult height near the initiation of GH therapy in May 2005 was in the 51 to 52.5 range. The patient had normal IGF-1 and IGFBP-3 levels three months after beginning his GH therapy. His parents have requested authorization for GH therapy which the Health Plan has denied based on their determination that it is not medically necessary.The patients initial workup suggested GH deficiency and it remains possible that he does have impairment of GH secretion. However, the more recent evaluation suggests idiopathic short stature with a low predicted adult height. GH therapy is medically appropriate on that basis as approved by the Food and Drug Administration in July 2003.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy, nine hours per month of supervision and two hours per month of parent training. Findings:  The physician reviewer found that ABA therapy at the frequency of 20 hours per week of direct, nine hours per month of supervision and two hours per month of parent training are medically necessary for treatment of the patients ASD. The study showed that ABA is effective for addressing disruptive behaviors in school aged children. The patient has made some gains with ABA therapy, however he continues to have aggression. In addition, the most recent progress report shows an increase in inappropriate attention gaining behavior and insistence on routine behavior. 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 with sub-specialty certification in developmental-behavioral pediatrics 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 authorization and coverage for Repatha 140 mg/ml SureClick injections for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has documented coronary and vascular disease as well as hyperlipidemia. The records document intolerance to several statin medications and Zetia. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 1 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, PCSK9 inhibitors have been demonstrated to be effective at lowering cholesterol and are associated with improved cardiovascular outcomes. Thus, Repatha 140 mg/ml SureClick injections are medically necessary for the 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 internal medicine with sub-specialty certification in cardiovascular disease 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: An enrollee requested reimbursement for the lumbar spine magnetic resonance imaging (MRI) for evaluation of the enrollees bilateral leg pain and burning. Findings:  The physician reviewer found that the review of the records provided for review demonstrates that the patient did not report any antecedent trauma. In addition, the provider did not note any concern for infection or metastatic disease. The patient has had a normal neurological examination including reflexes and a negative EMG for large fiber neuropathy. Thus, no red flags were present in the records. Per the National Imaging Associates (NIA) guidelines, the lumbar spine MRI was not medically necessary without a prior trial of conservative therapy. This patients records indicate the patient was referred for physical therapy but do not document that the patient was treated with physical therapy prior to the lumbar spine MRI. Thus, the lumbar spine MRI performed was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

The parent of a 14-year-old male enrollee has requested continued residential treatment center level of care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Due to multiple factors and unique considerations, determination of the appropriate level of care for patients with mood and anxiety disorders coupled with strained family dynamics and substance use is a challenging endeavor.  In this case, the documentation provided fails to demonstrate that the patient could not consolidate meaningful treatment gains in a less restrictive level of care.  There were no reports of consistent outpatient psychotherapy, chemical dependency counseling, or placements in intermediate settings such as intensive outpatient programming or partial hospitalization.  In general, such interventions are preferred initially as treatment of individuals within their community and family system optimizes therapeutic gains.  The medical records from the residential facility do not include a comparison of residential placement with less restrictive alternatives, or describe any behaviors, symptomatologies or medication adjustments that would require treatment in a 24-hour supervised setting.  All told, continued residential treatment center level of care from the dates indicated was not and 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 Otezla 30 mg tablets, 60 tablets for 30 days.Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. About 20% of patients suffer from severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. Up to 30 percent of psoriatic patients develop psoriatic arthritis, a type of inflammatory arthritis. The long-term use of traditional systemic therapies is frequently unacceptable due to toxicity and limited efficacy. The use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. However, patients treated with anti-TNF drugs may develop adverse events. Otezla is an oral phosphodiesterase-4 (PDE-4) inhibitor that provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Apremilast (brand name Otezla) has been studied in more than 4,000 patients, and the safety profile is consistent across indications. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. The physical limitations and risks associated with injectable biologics support the use of Otezla for treatment of this patient. Accordingly, the requested medication Otezla 30 mg tablets, 60 tablets for 30 days, is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of 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: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested therapeutic activities for the treatment of her low back pain. Findings:  The physician reviewer found that there is insufficient evidence in the literature to support the benefit of the prescribed program of computer-assisted exercise over standard physical therapy for chronic low back pain. In contrast, standard physical therapy including strengthening and stretching exercise, modalities, and transition to a home exercise program is more consistent with standard clinical practice, and as the literature suggests, may result in greater improvement in symptoms. The evidence does not demonstrate that computer-assisted exercise results in any added benefit over standard physical therapy for the treatment of low back pain.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old male enrollee has requested the medication Fentora 600mcg for treatment of his polyarteritis nodosa.   Findings:  The physician reviewer found that there is no clear evidence of a diagnosis presented in the provided records. The pain specialist states the patient has hereditary autoimmune polyarteritis nodosa. Certainly there are hereditary forms of neuropathy and polyarteritis nodosa (PAN) is a standard rheumatologic diagnosis; however, insufficient information has been provided to support a diagnosis. Furthermore, if the patient actually has PAN, there is no evidence he is receiving treatment relevant to that diagnosis. Reliance on pain medications would not be consistent with standard management of PAN. If he has a significant neuropathy causing pain, no evidence is presented to support such a diagnosis. All told, there is insufficient clinical evidence to support the use of Fentora in this setting.