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

A 69-year-old male enrollee has requested for Provigil for treatment of his daytime sleepiness. Findings:  The physician reviewer found that fatigue is a common problem in Parkinson's disease, often the most troubling of all symptoms. It is poorly understood, generally under-recognized, and has no known treatment. Medications for Parkinsons disease can have sedating side effects, but dose reduction can lead to immobility and other disabling motor symptoms. No medications have been approved for treatment of Parkinsons disease-related sedation and excessive daytime sleepiness. Other medications, such as Ritalin, are used, but are not FDA approved for this condition. Clinical studies have demonstrated mixed evidence in favor of Provigil for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for group 3 power wheelchair K0856 for treatment of the enrollee who has a history of polio (non-ambulatory).Findings:  The physician reviewer found that The records do not establish that the patients mobility related activities of daily living could not be met with a group 2 power wheelchair. The patient in this case is able to stand to urinate, perform weight shifts to prevent pressure ulcers and propel a manual wheelchair for shorter distances.  Group 2 wheelchairs are otherwise distinguished versus higher performance group 3 wheelchairs in the following areas: group 2 power wheelchairs can overcome obstacles of 40 mm in height (60 mm for group 3); group 2 power wheelchairs have a minimum top end speed of three miles per hour (4.5 mph for group 3); group 2 power wheelchairs have a range of seven miles (12 miles for group 3); and group 2 power wheelchairs are dynamically stable at up to six degrees (7.5 degrees for group 3). There are subdivisions within each respective group for various weight capacities including extra heavy group 2 power wheelchairs for patients whose weights exceed 600 pounds. Power wheelchairs are not designed or meant to carry large amounts of personal property, which would negatively alter its stability by increasing the height of the center of gravity. American with Disabilities Act compliant ramps must have a slope of no less than 12 units run for one unit rise (4.76 degrees), which is within the minimum capacity of a group 2 power wheelchair (Americans with Disabilities Act). This group of wheelchairs is reserved for persons with severe impairments. Typical conditions for which this group of wheelchairs are prescribed appropriately include amyotrophic lateral sclerosis, stroke with hemiplegia, spinal cord injury with tetraplegia, cerebral palsy, muscular dystrophy, advanced Parkinsons, and advanced multiple sclerosis.  Therefore, according to the documentation submitted, group 3 wheelchair K0856 is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested  acute inpatient rehabilitation for medical treatment of his traumatic brain injury.  Findings:  The physician reviewer found that notes document the patients pain and tone control are both good, and he has functionally made continued gains in all areas. In addition, his impairment with problem solving and higher subjective reasoning skills are improving. Thus, continued stay in acute rehabilitation is not medically necessary. Based on the clinical documentation provided including digital videos, the request for acute inpatient rehabilitation stay is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee requested Nutropin AQ NuSpin for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patients fall-off in growth velocity occurred at a time of concomitant weight loss and complaints of abdominal pain and diarrhea.  The patients pre-treatment growth factors were normal, he had no known morphological abnormality of the pituitary gland on MRI and he did not fail two standard provocative growth hormone tests.  Thus, he did not meet standard criteria for growth hormone deficiency prior to initiation of growth hormone therapy.  Other causes of the patients transient growth fall-off were not definitely ruled out prior to initiation of growth hormone therapy.  The fact that the patients growth velocity picked up after initiation of growth hormone therapy does not prove that he was growth hormone deficient, as growth hormone was administered after the patient had already started puberty, as evidenced by pubertal levels of gonadotropins prior to treatment.  Thus, concomitant secretion of endogenous sex steroids likely augmented the effect of growth hormone on statural growth.  The patient did not allow for genitourinary examination, and so it cannot be stated with certainty that the patient did not progress in puberty between the pre-treatment evaluation and post-treatment assessment.  All told, the requested Nutropin AQ NuSpin treatment is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 49-year-old female has requested approval for past breast surgery performed on an emergent basis.  Findings:  The physician reviewer found that the patient underwent breast surgery outside of the United States. She reports that the procedure was performed on an emergent basis. The patients clinical history, pre-surgical work-up and operative report have not been provided. At issue in this case is whether a prudent layperson would have sought immediate medical attention on the date at issue. 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.The patient maintains that she was extremely ill at the time she presented to her provider outside of the United States. Medical records detailing the patients clinical signs and symptoms at the time of presentation have not been provided. It appears a bilateral breast reduction was performed, although the operative report has not been provided. A letter from the patients surgeon states that the patient had surgery for fibrocystic changes however a bilateral excision procedure for fibrocystic changes is not an emergent procedure. No evidence of breast infection has been provided; even if the patients condition was related to a breast infection, it is likely that mastitis could have been treated simply with antibiotics. If the patient had developed a breast abscess, it is extremely unlikely that she would have bilateral abscesses at the same time, and typically an abscess would be treated with antibiotics, possible incision and drainage but not bilateral excision surgery. There is no documentation or history of trauma. Trauma to the breast would have to be extensive to involve bilateral excision procedures. If the patient had presented with pain from fibrocystic changes, simple pain management would have been appropriate with non-steroidal anti-inflammatory medication or even narcotic analgesics. A mass or breast lump is typically the most common reason for a breast biopsy however a breast mass does not typically present with acute breast pain and is not typically performed bilaterally. Further, the patients surgeon did not document or imply that this was a work-up for cancer, pathology, etc.  All told, the submitted documentation does not detail the specifics of the patients reports of illness or how the illness was related to the acute onset of pain, fever, or possibly a recent traumatic insult to the breasts. As such, there is no evidence to demonstrate that a prudent layperson would have sought immediate bilateral breast surgery on the date at issue.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left lower extremity and joint. The American College of Radiology (ACR) state that MRI of the knee for evaluation of pain after a total knee arthroplasty is not supported as the initial imaging evaluation. MRI may be appropriate as additional imaging following radiographs for pain after total knee arthroplasty when joint aspiration cultures are negative or inconclusive, or if there is a suspected infection. This patient presents with chronic left hip, knee and foot pain with reported frequent lower extremity cellulitis. She is status post left total knee replacement, which she indicates is possibly infected. She states that her provider recommended a sit-down MRI, as she was unable to lay down for a traditional MRI due to pain. The records suggest the provider recommended a sit-down MRI to assess the left knee for hyperbaric chamber treatment. However, there is no discussion of an infection work-up to support the current role of MRI in this patients clinical scenario. Additionally, there are no indications for the medical necessity of a sitting MRI for evaluation of the left lower extremity over a standing MRI. All told, the requested MRI of the left lower extremity and joint is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are 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 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

The parent of a five-year-old female has requested coverage of  speech therapy for treatment of her moderate expressive and receptive language delay and severe articulation delay.  Findings:  The physician reviewer found that per Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  In this patients case, she demonstrates moderate receptive and expressive language deficits and severe articulation deficits that negatively impact her ability to communicate with family and peers as well as achieve age-appropriate functional communication skills. Studies have shown that speech and language therapy can result in significant improvement in such children.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for circumcision. Final Result: The reviewer determined that the submitted documentation fails to demonstrate the medical necessity of the requested services. Based on the available documentation, the patient does not have medical problems or conditions for which a circumcision would be indicated. He did not report voiding complaints or a history of recurrent balanitis or urinary tract infections. Physical examination did not reveal penile abnormalities. Performing a circumcision for redundant foreskin for abnormal odor is not considered a clinically appropriate and generally acceptable standard of care. As such, the requested circumcision is not medically necessary for the treatment of this patient. Credentials/Qualifications: The reviewer is board certified in urology 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 46-year-old female enrollee requested authorization and coverage for enrollment in a phase I clinical trial. The health plan has denied this request indicating that the proposed trial is not medically necessary for treatment of the enrollees metastatic colon cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested clinical trial is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Hyqvia subcutaneous infusions for treatment of the enrollees immune deficiency. The physician reviewer found that primary immunodeficiencies are a group of disorders that have in common defective antibody production, rendering those affected with recurrent bacterial infections.  One type of immunodeficiency is IgG subclass deficiency.  Patients with IgG subclass 3 deficiency can experience recurrent respiratory infections, and treatment involves immunoglobulin administration.  Hyqvia is a subcutaneously administered immunoglobulin product indicated for treatment of primary immunodeficiency. The hyaluronidase is used as a facilitating agent to allow large volumes of fluid to be absorbed subcutaneously.  The rate of adverse events is lower than with parenteral administration of intravenous immunoglobulin.  This patient has a longstanding history of atopic disease requiring multiple routine and rescue medications as well as recurrent sinusitis.  Based on the current literature, she would benefit from administration of Hyqvia, a subcutaneous hyaluronidase-facilitated IgG infusion.  All told, the requested Hyqvia subcutaneous infusions are medically indicated 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee has requested for intensity modulated radiation therapy (IMRT) for treatment of his prostate cancer. Findings:  The physician reviewer found that IMRT is an established technique of radiation delivery which potentially affords even more precise radiation dose delivery of escalated doses, in appropriate cases, to targeted tumors, while sparing nearby healthy tissue structures. IMRT has the capability of generating concave dose distribution and tight dose gradients and is felt to be well-suited to the treatment of prostate, to avoid exposure of the rectum, small bowel and bladder. A number of indirect studies exist that describe the dose volume toxicity advantages of IMRT over non-IMRT radiotherapies. Multiple dosimetric and treatment planning comparative studies have favored IMRT over 3D conformal radiation treatment in the treatment of localized prostate cancer. IMRT has demonstrated improved conformality to and homogeneity within the target tissue. It has been hypothesized that IMRT may improve treatment outcomes by permitting escalated tumor doses without increasing normal tissue toxicity. There is evidence from randomized control trials showing a dose response relation above 68 Gy for local and biochemical control of prostate cancer. In addition, dose volume toxicity relations have been established for rectal bleeding and other gastrointestinal and genitourinary toxicity. Veldeman and colleagues concluded that IMRT creates a window for dose escalation with unchanged or lower gastrointestinal and genitourinary toxic effects. Zelefsky and colleagues showed that the use of IMRT reduces risk for grade 2 or greater gastrointestinal toxicities compared with patients treated with 3D conformal radiation treatment from 13% to 5%. Guidelines on prostate cancer treatment from the National Comprehensive Cancer Network were revised in 2008 to add IMRT to 3D conformal radiation treatment throughout the guideline.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for gene testing (gene expression profiling) for evaluation of the enrollees cutaneous melanoma. Findings: The physician reviewers found that the gene testing (gene expression profiling) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of gene expression profiling is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or health outcomes. All told, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in dermatology 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

Nature of Statutory Criteria/Case Summary: The parent a patient has requested authorization and coverage for Nutropin AQ Nuspin 20 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients idiopathic short stature. The submitted documentation does not support the medical necessity of the requested medication. Based on the medical needs of the patient and current practice guidelines, this patient does not meet criteria for growth hormone treatment for the diagnosis of idiopathic short stature for the following four reasons. First, there is no documentation of severe growth deceleration. Second, the patients estimated predicted height based on the bone age prior to growth hormone treatment (61 inches) falls within the range of the mid-parental target of (65 inches), although at the lower end of normal. Third, the patients estimated predicted adult height falls within the normal range for adult females and is at the 10th percentile. Fourth, the criteria for ISS is not met because this patient's height is not below standard deviations for the chronological age and sex. There is also no documentation to support other diagnoses for which growth hormone would be indicated. Therefore, Nutropin AQ Nuspin 20 mg 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 43-year-old female enrollee has requested for emergency services for treatment of his toe pain. Findings:  The physician reviewer found that the patient complained of right great toe pain after a vase fell on her foot. She had tenderness and a subungual hematoma on physical exam. While in the emergency department, her toe was x-rayed and her toenail trephinated (a hole placed to drain the blood). She was given oral narcotic analgesics for pain control. The patient had a subungual hematoma that required trephination for drainage. She also required evaluation for possible fracture. Had there been a fracture present, the patient would have required antibiotics for prophylaxis against infection as it would have been an open fracture after the trephination.