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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Humatrope 5 mg for treatment of the enrollees septo-optic dysplasia and associated panhypopituitarism.Findings:  The physician reviewer found that The request for Humatrope 5 mg is not medically necessary for treatment of the patients medical condition. The patient has documented panhypopituitarism and should continue on full pituitary replacement as determined by his provider. However, there is a lack of documentation supporting brand name Humatrope as medically necessary. The Health Plans formulary medication such as Nutropin is medically appropriate in this clinically setting. As such, the requested medication has not been established as medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 the RT300 FES cycle therapy system for treatment of his medical condition.  Findings:  Two physician reviewers found that the FES cycle has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of FES cycling and the net weight of evidence has been positive, showing that FES cycling promotes improved health status in patients with spinal cord injury. The patient is paraplegic due to a spinal cord injury. This immobility is well known to often result in osteoporosis, atrophy, and increased risk for cardiovascular disease. Kahn and colleagues showed lower extremity cycle ergometry may reduce the risk of cardiovascular disease. Hammond and colleagues found a 42% decrease of developing osteoporosis in patients with spinal cord injury who use FES. Kuhn and colleagues evaluated FES use in spinal cord injury rehabilitation and demonstrated that it has a positive influence on spasticity and walking ability. The literature shows the requested RT300 FES cycle therapy system can provide many therapeutic benefits for this patient and is likely to be of more benefit than any available standard therapy.  Final Result: Two reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his gastroesophageal cancer.  Findings:  Three physician reviewers found that IMRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The standard of care for radiation of esophageal cancer is 3D conformal radiotherapy (3DCRT). Although there is support in the medical literature for IMRT treatment for esophageal cancer, these studies are single institution studies with a few patients and no long-term follow up. Moreover, there is a lack of randomized trials or large cohort studies supporting superior clinical outcome of IMRT compared to 3DCRT. In absence of level I evidence, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

An 18-year-old female enrollee requested genetic testing, cytogenetic microarray testing for copy number variation for medical evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that the requested services are likely to be more effective than other modalities.  This patient has intractable epilepsy.  Olson and colleagues noted that copy number abnormalities may have an important role in patients with epilepsy.  The authors recommended the implementation of chromosomal microarray testing for evaluation of unexplained epilepsy.  Medical studies have shown that identification of a genetic basis for epilepsy can result in different treatment options.  This patient may benefit from genetic testing, with resulting better understanding of the source of her intractable seizure disorder, and resulting alteration of the treatment regimen.  Therefore, the requested cytogenetic microarray testing for copy number variation is likely to be of greater benefit than other available alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve block injection.Findings:  Three physician reviewers found that there is a lack of support for the requested services in this patients case. The records document hypertension, type 2 diabetes mellitus and peripheral neuropathy. The patient reported pain and numbness in her feet. She has been prescribed Norco for pain. The records do not document trials of other oral pain medications for neuropathic pain. The American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine noted peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.  Evidence-based clinical practice guidelines do not support the use of peripheral nerve blocks for neuropathy. In this patients case, the records do not document trials of oral anticonvulsants or other medications that are used to treat peripheral neuropathy. Therefore, the requested peripheral nerve block injection is not likely to be superior over other treatment options. Final Result: The reviewers determined that the 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: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 authorization and coverage for Botox injections. Findings:  The physician reviewer found that Botox is a muscle relaxant which has been found to have analgesic effects in patients with a variety of pain syndromes. Data from clinical trials confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine, the most severe and debilitating type of migraine, in adults. The peer-reviewed literature demonstrates that Botox injections for the treatment of chronic daily headache and migraine are effective for children. Its effective use, safety and tolerability have been demonstrated in several pediatric studies. This study described10 patients ages 11-17 with chronic daily headache refractory to treatment that were given Botox injections. The patients had failed to respond to an average of eight prior medications. In the study group, four patients treated with Botox had meaningful relief of their headache with improvement in their quality of life and two patients had a decrease in their headache frequency. Another study performed a retrospective review of all patients who received Botox for chronic migraine in a large pediatric headache center. The authors recommended Botox injections for pediatric patients with chronic headache if they fail two or more preventive medications. Their study showed a major change in the frequency of the headache with a statistical difference in the improvement of headache days per month. In this case, the patient has tried several therapeutic trials, including a tricyclic antidepressant medication, sertraline, biofeedback, acupuncture and massage without headache relief. As such, the request for Botox injections has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in pediatrics and neurology with special qualification in child neurology 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

Twenty-three year-old female patient has been diagnosed with severe, recurrent, major depression starting at the age of 11 to 12 years and has been treated with numerous medications, as well as psychotherapy and electroconvulsive therapy. She has been admitted to inpatient psychiatric care a number of times. In spite of all these interventions, her symptoms of depression have continued. The patient reportedly has decreased activity, increased sleep, poor concentration, social isolation, decreased appetite, irritable mood, suicidal ideation and self-injurious behaviors.  Reviewers Findings:  The reviewing physicians concluded that the psychiatric community at large has not yet embraced VNS therapy as part of the national standard of care for severe depression. The American Psychiatric Association (APA) has gone on record in stating, While VNS therapy has been studied over the past five years, evidence is not yet sufficient to recommend its use in routine clinical care. VNS therapy is not, at this time, included in the APA treatment guidelines for major depression. That said, it is very likely a future iteration of the guidelines will include a recommendation regarding the use of VNS therapy for carefully selected patient and provide a stringent protocol-driven selection process. Clinical and preclinical research with VNS therapy is ongoing and when sufficient data is accumulated the role of VNS therapy in the treatment of depression will become clearer. Until that time recommendations for its use for patients such as this one are premature. Therefore, the reviewers found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The father of a 15-year-old male enrollee has requested for psychiatric residential treatment services for treatment of the enrollees behavioral health problems.            Findings:  The physician reviewer found that his impairment is significant and long-standing. He recently failed in another treatment program due to his aberrant behaviors, which could be accepted as the equivalent to failure of intensive outpatient and partial hospital program services. The patient meets the criteria for a residential level of care. He clearly has a pattern of impairment of psychosocial functioning due to his psychiatric illness. He has a clinical need for 24-hour structure, supervision and active treatment.  Furthermore, it is likely that his condition will deteriorate without residential care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a compound prescription Biest/progesterone TD cream, composed of: Estriol micropowder 0.24 grams, Estradiol micro-powder 0.06 grams, progesterone micro-powder 7.5 grams, propylene glycol 7.5 mL liquid, and Vanicream 59.7 grams. Researchers note that menopausal hormone therapy (also called hormone therapy or hormone replacement therapy) may treat menopausal symptoms including hot flashes, sleep disturbances, mood lability and depression, and joint aches and pains. The authors noted a lack of evidence supporting the safety or efficacy of custom compounded bioidentical hormone therapy when compared with approved and commercially available products for menopausal hormone treatment. Researchers state that there is no rationale for routine prescribing of unregulated, untested, and potentially harmful custom-compounded bioidentical hormone therapies. Given that there are multiple formulations that are approved by the U.S. Food and Drug Administration (FDA) for menopausal hormone therapy (MHT), the requested medication is not medically indicated. Therefore, a compound prescription Biest/progesterone TD cream, composed of: Estriol micropowder 0.24 grams, Estradiol micro-powder 0.06 grams, progesterone micro-powder 7.5 grams, propylene glycol 7.5 mL liquid, and Vanicream 59.7 grams is not medically necessary for the 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 obstetrics and gynecology 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 67-year-old female enrollee has requested the LINX Reflux Management System for treatment of her gastroesophageal reflux disease. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment alternatives.  The LINX device has been approved for patients with chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  Appropriate patient selection is crucial before anti-reflux procedures.  This patient has gastroesophageal reflux disease based on her pH recordings.  However, it appears she has benefitted to a significant degree from acid suppression treatment.  Thus, the records do not demonstrate that she is refractory to acid blocker drugs.  Additionally, the documentation does not show that the patient has worsening bone mineral loss due to medical management of her gastroesophageal reflux disease.  Available records do not document by serial DEXA scanning progressive osteopenia/osteoporosis.  Therefore, the LINX Reflux Management System is not likely to be of greater benefit than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of inpatient residential behavioral health services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees depression and post-traumatic stress disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old male who has a history of osteoarthritis in both knees and spondylolisthesis at L4-5. In addition, the patient also states he has poor circulation and chronic lung problems. The records state the patient is unable to operate a manual wheelchair long distances because of upper extremity pain. The Health Plan has denied the patients request for a power-operated vehicle (POV) on the basis it is not medically necessary.The records submitted do not state an actual diagnosis for the patients chronic lung problems. In addition, there is no documentation stating whether the patient is ambulatory in his home. Nor is there documentation indicating whether a POV can be used inside the patients home. Based upon the information provided, I have determined that the requested equipment is not medically necessary for the patients mobility at this time. However, if there is documentation the patient is able to use a POV for mobility inside the home and is unable to ambulate within the home, the patients request for a POV should be reconsidered. As such, the Health Plans denial should be upheld at this time.
Appeal type: Urgent Care
Decision: Overturned

A 51-year-old male enrollee has requested emergency services for treatment of his medical condition.   Findings:  The physician reviewer found that the issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the enrollees presenting history, believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. This patient had a headache of undetermined etiology which was described as extreme in its pain, and was unremitting over four days. He consulted his primary care provider. A letter from his primary care provider states the patient was advised to go to the emergency room by our office... In light of the patients pain level as well as the advice he received from his primary care provider indicating that he should go to the emergency room, a reasonable and prudent layperson in this situation would have believed he was experiencing a medical condition requiring immediate medical attention. Therefore, the patient met prudent layperson criteria for emergent care on the date of service in question.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cardiac computed tomography (CPT 75571). Based on standard risk factor calculations, this patients 10-year cardiovascular risk is low. However, her low-density lipoprotein is close to recommended statin treatment levels and she has a diagnosis of Crohns disease, which significantly raises her risk of developing cardiovascular disease. Findings:  The physician reviewer found that in addition, she has been unsuccessful with diet and exercise in lowering her body mass index and improving her overall cardiovascular risk and lipid profile. Given these additional clinical factors, statin therapy should be considered. Further risk stratification with computed tomography calcium scoring has been shown to be useful in determining the need for lifelong statin therapy in this type of indeterminate clinical situation. Given this support, the cardiac computed tomography (CPT 75571) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the cardiac computed tomography (CPT 75571) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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 31-year-old male enrollee has requested genetic testing for evaluation of his myotonia congenita.  Findings:  The physician reviewer found that review of the literature indicates that there are over 50 mutations to the gene involved in myotonia congenita. In addition, genetic analysis of patients suspected to have either the dominant or recessive form of the disease is informative in only 50% of patients. Given this, and the fact that no pedigree analysis has been presented in the case, there is no evidence to support genetic testing in this setting. There is a high probability that such testing will be non-informative.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage of bilateral Unispacer knee surgery for the treatment of osteoarthritis in both knees.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that bilateral Unispacer knee surgery is not likely to be more beneficial for treatment of the enrollees osteoarthritis in both knees than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.