Persius/imr-appeals huggingface dataset:
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 addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. The additional three dimensional imaging allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue, offers increased cancer detection, and allows better characterization of possible masses, spiculation, and architectural distortion. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the diagnostic procedure 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: 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: Medical Necessity
Decision: Overturned

The parent of a two-year-seven-month-old male enrollee has requested for speech therapy for treatment of the enrollees expressive language delay. Findings:  The physician reviewer found that according to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties (Bernhardt and Major). These reviewers concluded that the meta-analysis showed that there is a positive overall effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. This patient is a young male with mild receptive language deficits, severe expressive language deficits, and severe articulation deficits which negatively impact his ability to achieve age appropriate functional communication skills. Studies have shown that speech and language therapy can result in significant improvement in this patient population. The requested speech therapy is appropriate at this time given the nature of the patients deficits.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee requested graft product of an ankle wound for medical treatment of his wound.  Findings:  Three physician reviewers found that the documentation submitted for review did not indicate the patient had a deep dermal or full thickness wound.  The records noted eschar measuring 3.5 cm x 2 cm.  There were no exposed tendons, no malodor, and no purulence.  It was noted the wound was dry with a stable scab on the front of his leg.  Per the medical records, this patient did not have a chronic non-healing wound which would require a skin graft.  All told, graft product of an ankle wound  was not likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 68-year-old female enrollee requested authorization and coverage of nebulized tobramycin solution for inhalation with the SinuNEB system. The Health Plan denied the request indicating that the requested treatment is considered experimental for treatment of the enrollees chronic sinus and nasal symptoms.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old male with diagnoses of HIV and hepatitis C virus. He is on multiple medications. The patient reports that he experiences exhaustion and fatigue and falls asleep at his desk while at work. His provider recommended Provigil 200mg for the patients symptoms of fatigue related to HIV and hepatitis C virus. At issue is whether Provigil is medically necessary for treatment of the patients condition.Provigil is not medically necessary for this patient. There is no data to support the use of Provigil for treatment of HIV and/or hepatitis C related fatigue or to offset the effects of the patients medications. The use of Provigil in this setting is not within the standard of care or consistent with generally accepted community practice. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old woman who is two years status post bariatric surgery. The patient has reportedly experienced a 150-pound weight loss. The submitted photographs demonstrate multiple areas of trunk skin excess. The patient reports pain in the buttock area upon sitting. The patient wishes to undergo a surgical procedure to resect the redundant skin and residual adipose of her trunk. She was examined by two plastic surgeons who determined that the discomfort complained of was not explainable by the presence of the patients excess skin and that other studies should be carried out. The Health Plan has denied the patients request for a trunkplasty on the basis that it is not medically necessary. The submitted documentation confirms the examining physicians findings. Although the patient reports pain in the buttock area upon sitting, there is no demonstrated etiology for the patients pain. It is unlikely that the skin folds themselves would cause pain. Additionally, there is no evidence of intertrigo, which would cause burning pain. Thus, there is no evidence that the requested procedure would alleviate the patients pain. Furthermore, there is no other documented symptomatology that would warrant a trunkplasty. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for molecular markers test. Findings:  Two of the three physician reviewers found molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC.  Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Thus, molecular markers test was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for extraction of two teeth (numbers 1 and 16) and anesthesia provided for the treatment of the enrollee, who reported jaw pain and headache. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The records documented that teeth numbers 1 and 16 were impacted. There was inadequate space for ideal eruption and maintenance of oral hygiene. Left untreated, the retained third molars were likely to have resulted in disease with dental and medical consequences. Studies have demonstrated that removal of wisdom teeth when a patient is younger is prudent and results in decreased complications and improved recovery. Given the patients age, anxiety and nature of the procedure, performance of the procedure with anesthesia was medically appropriate.  All told, extraction of two teeth (numbers 1 and 16) and anesthesia provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for tongue tie surgery. Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the requested procedure in this clinical setting. Ankyloglossia is a congenital condition in which an infant has an abnormally short of thick lingual frenulum, limiting the movement of the tongue anteriorly or posteriorly. It is typically noticed upon inability to breastfeed successfully. It is more common in males and occurs in 5 to 10% of live born infants. While typically associated with limitations in breastfeeding in young infants, ankyloglossia also can have other negative sequelae, such as choking and difficulty advancing the diet such as in this patients case. Delay in speech and language development may also occur due to this condition. Intervention includes frenotomy for young infants and frenectomy with or without frenoplasty in the older infant and child. According to the medical literature, these are safe procedures with associated benefits in breastfeeding, eating, and talking. This patient was noted to have ankyloglossia when he developed choking upon introduction of solid foods. Although solid foods are age and nutrition appropriate for him, there is concern for choking hazard and aspiration in his current state. In addition, speech and language development may be negatively affected by restricted tongue movement. Surgical intervention is recommended and clinically appropriate. Therefore, tongue tie surgery is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. The Health Plan has denied this request indicating that the services at issue were not emergency medical services. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The patient presented with a history of major depression with severe, single episode, without psychotic features, generalized anxiety disorder, panic disorder with agoraphobia, thoughts of harming others, and obsessive compulsive disorder (OCD). The multiple diagnoses, notably agoraphobia, and possibly OCD, are not supported by the history or symptoms. The patient has multiple friends, is active in surfing, soccer, and skateboarding, and attends school regularly. The services at issue were not necessary for treatment of a psychiatric emergency medical condition.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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested cryoablation therapy for treatment of her breast fibroadenoma. Findings:  Two physician reviewers found that although cryoablation therapy was approved by the Food and Drug Administration (FDA), the small number of studies evaluating the safety and efficacy of cryoablation provide limited insight into long-term patient outcomes. The largest study to date was conducted by Nurko and colleagues and demonstrated that 28% of the patients treated with cryoablation still had a palpable lesion in the treatment area at 1-year follow-up. More prospective, randomized, controlled studies need to be undertaken to establish whether cryoablation has a clinical role in treatment of patients with benign fibroadenomas. In the alternative, the American Society of Breast Surgeons (ASBS) recommends surgical resection for unsuccessful and incomplete excisions. The positive outcomes have been extensively studied and one advantage with surgical excision is the acquisition of a sample for pathological evaluation. This patient desires to have the lesion removed due to its recent increase in size and wishes to avoid surgery given the previous breast biopsies. The previous breast surgeries were more diagnostic in nature and were not designed to be definitive treatments. It is most likely that the standard option of compete surgical excision will prevent recurrence of this particular lesion and will enable pathology to evaluate for possible malignancy. Therefore, the requested cryoablation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male has requested laparoscopic gastric banding (Lap Band) surgery for treatment of his obesity.  Findings:  The physician reviewer found that based on review of the available records, this patient meets all generally accepted criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. Specifically, the patient has a documented BMI that is greater than 35, and co-morbid conditions including obstructive sleep apnea, asthma, and GERD. The patient has reportedly failed dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery. Consistent with these findings, the requested surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested authorization and coverage for an electrophysiology study and catheter ablation procedure. The enrollee has a history of extra heartbeats. Her physician reports these are very frequent. They are causing symptoms of chest pain, shortness of breath, and lightheadedness. She is unable to sleep because of these symptoms and has gone to the emergency room because of the discomfort. The enrollee has tried medications and experienced bad side effects. Her physician wants to use energy to make tiny scars in the heart to stop the extra heartbeats from happening. Literature shows that, if the extra heartbeats are not treated, they can cause other illnesses and problems. Since the enrollee cannot take the medications, this procedure is a good way to fix the problem.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease 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: Medical Necessity
Decision: Overturned

A 24-year-old male enrollee requested authorization and coverage for orthognathic surgery (Maxillary lefort 1 osteotomy and bilateral sagittal mandibular osteotomies) for the treatment of severe class III malocclusion, masticatory dysfunction/dysphasis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for direct one-to-one applied behavioral analysis (ABA) therapy, at 40 hours a week. In this case, the patient presents with behavioral issues including non-compliance, inflexibility, outburst behaviors, and elopement when asked to make low preference transitions. The patient also continues to participate in socially impairing stereotypical behaviors. A treatment plan has been developed that is consistent with the patients essential health needs and consistent with the diagnosis of autism. ABA as a treatment is evidence based and scientifically proven to be effective. The purpose of ABA in this case is promote independence for the patient by addressing his current behavioral deficits. Regarding the number of hours of ABA therapy,  a study reported that a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. This patients records indicate that he made progress in many areas, but continues to demonstrate significant behavioral concerns, which have increased dramatically after the decrease in ABA hours. The patient continues to require a high level of support to transition appropriately. Failure to master these skills places the patient at an increased risk for injury and makes it difficult to be successful in more generalized environments. Given these findings, the requested direct one-to-one ABA therapy, at 40 hours a week is supported as medically necessary for treatment of this patients medical condition. 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 neurodevelopmental behavioral pediatrics and genetics 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: Urgent Care
Decision: Overturned

A 62-year-old male enrollee has requested emergency services for treatment of his abnormal behavior.  Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention for the patient. The patient was experiencing acute paranoia and was actively hallucinating.  His medical condition was of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy and potential harm to others. The visit to the emergency department on the date indicated was appropriate; the patient was experiencing active psychotic symptoms on that day and it appears his family was unable to secure immediate care through the patients primary care physicians office. As such, the patients symptoms on the date indicated met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck without dye. Findings:  The physician reviewer found that conventional radiographs are the first step in the evaluation of neck pain, particularly to diagnose degenerative disease, post-surgical complications, spinal stenosis or malalignment. After radiographs are obtained, a subset of patients may benefit from further imaging utilizing MRI or computed tomography (CT). According to the American College of Radiology appropriateness criteria for the evaluation of chronic cervical or neck pain with degenerative changes seen on initial radiographs, MRI is usually appropriate for further evaluation. MRI is the optimal examination for the evaluation of intervertebral discs, facet arthropathy, nerve root compression and spinal stenosis. It can also demonstrate abnormalities present within the spinal cord, which may be the cause of neck pain. These findings may not be visualized on initial radiographs and could alter the patients management. In this case, in the setting of chronic neck pain which persists despite conservative treatment, MRI is indicated for further evaluation. Therefore, MRI of the neck without dye (CPT 72141) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.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.