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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Norco for treatment of his hip and back pain. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Norco has not been established. Such narcotics are presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. Additionally, the dose of Norco poses a risk for acetaminophen toxicity. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons provided, the patients request for Norco is not medically necessary. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) myelogram. Review of the submitted documentation supports the medical necessity of the requested MRI myelogram. The records indicate there are no signs of intracranial hypotension on the MRIs of the brain and these signs are generally present in cases of CSF leaks.  However, there are cases (approximately 25%) where no such finding is present and yet the individual has a CSF leak. Thus, it has been established that a CSF leak may be present despite a normal brain scan. Given the possibility that the patient may be experiencing a CSF leak despite her normal MRI results, a MRI myelogram is medically appropriate and reasonable in this case. As such, there is sufficient evidence to support the medical necessity of the requested MRI myelogram for further work-up and evaluation of the patients condition.Final Result: The reviewer determined that the requested service is 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 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: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested a continuous glucose monitoring system (CGMS) and related supplies for the treatment of his type I diabetes. Findings:  Two physician reviewers found that there is no information provided documenting that the patient had a wide variability in his finger stick blood sugar results, frequent irreversible lows or significant complications prior to the use of the CGMS. In addition, it appears the patients diet may be a contributing factor to his reported poor control. There is no indication the patient has seen a dietician to evaluate his meal plan or eating patterns. As such, there is inadequate evidence to support this patients use of a CGMS.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female less than one year postoperative from gastric bypass surgery.  Her weight had decreased by 168 pounds as of October 2005.  The patient is troubled by macerated skin under the pannus and multiple regions of excess skin.  She is requesting authorization for panniculectomy and body contouring procedures. The Health Plan has denied the request citing a lack of medical necessity.The record submitted for review included limited medical records, a note from a plastic surgeon, copies of photographs of the patient, and letters from the patient. From these documents there is evidence the patient is still in the process of weight loss with early hanging of excess skin. In October 2005, it was noted by the consulting specialist that the patient was on her diet regimen and was losing approximately one pound per week. There is however, no evidence of medical necessity for the proposed procedures at this time. The Health Plan is correct in suggesting that the patient await the complete results of the bypass procedure prior to consideration of surgical intervention. Therefore, I have determined the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested sacral nerve stimulation for the treatment of her fecal incontinence. Findings:  Two physician reviewers found that the minimally invasive technique of sacral nerve stimulation (SNS) is safe and effective. Most adverse effects can be easily remedied. Data has demonstrated that SNS significantly improves patients quality of life, including their physical and psychological well-being. Sacral nerve stimulation is an effective and safe long-term treatment for fecal incontinence. Clinical outcome has been stable over time. There is adequate literature published regarding this issue and in this particular patient, sacral nerve stimulator is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for bilateral mastopexy and belt lipectomy. The enrollee has excess skin as the result of a 200-pound weight loss. The enrollees surgeon reports the enrollee would have a deformed appearance without the breast lift and reports the enrollee has excess skin hanging below her pubic line. Literature indicates mastopexy is designed to elevate breast tissue and to correct sagging breasts. Mastopexy will not improve health outcomes and is not clinically appropriate from a functional or medically necessary standpoint. It is being performed for appearance and enrollee convenience. The medical records do not demonstrate that ongoing, clinically significant abdominal skin problems have not responded to topical therapy, or, despite initial response, have recurred and caused significant problems. Supervised medical management for rashes is not documented in the progress notes. The enrollee is not sick because of her excess skin, and has not experienced ulcerations, panniculitis or sepsis from her infections.  A dermatologist has not evaluated the rashes.  The enrollee has not required hospitalization or treatment with antifungal or antibiotic medications. The alleged abnormality does not constitute an abnormal structure of the body because abdominal and hip skin redundancy is a normal anatomic occurrence associated with weight loss and aging.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral knee injections with Synvisc for treatment of the enrollees osteoarthritis of the knees.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this patients case, clinical examination findings are consistent with x-ray evidence of bone-on-bone osteoarthritis of both knees.  She has undergone two prior viscosupplementation series, with documented long-term pain reduction and improvement in walking tolerance.  She has failed to respond adequately to other conservative treatment, including anti-inflammatory medications. Therefore, bilateral knee injections with Synvisc are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 patient is a 37-year-old female with a body mass index (BMI) of 46. The patient has comorbid conditions including sleep apnea. It does not appear the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. The Health Plan has denied the patients request for gastric bypass surgery on the basis that it is not medically indicated.With a BMI of 46 and comorbid conditions such as sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested for emergency services. Findings: The physician reviewer found that 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. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with an acute knee injury. The patient was unable to straighten the knee and/or bear weight on the knee. He had pain with ambulation. The differential diagnosis of knee trauma in this case includes fracture of the tibial plateau, meniscal injury, anterior cruciate ligament tear, patellar dislocation, and others. These potential injuries may be of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions and/or serious dysfunction of the knee joint. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the ED services met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This patient demonstrates the optimal use for tomosynthesis. An initial diagnostic mammogram did not clearly delineate the patients abnormality after she presented with a palpable mass. The initial mammogram demonstrated heterogeneously dense breast tissue, which could obscure a tumor. She then had additional images which demonstrated better the area of distortion. Additionally, the ultrasound was performed to better distinguish the solid nature of the lesion. She then underwent an ultrasonically guided biopsy. It is specifically this type of patient with dense breasts and a palpable mass that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that Harvoni is medically necessary for treatment of the patients medical condition. According to the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In this case, the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV genotype 1. Moreover, the requested medication prevents further damage of the liver and progression of the disease process. 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 gastroenterology 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 16-year-old male enrollee has requested relationship development intervention (RDI) program services for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The patient has been in an RDI program since the age of 10. According to the submitted documentation, at the age of 12 years and 3 months, his language and cognition were equivalent to the age of 2 years and 6 months. Although the patients parent states RDI has been effective, an examination of the patient at the age of 15 years and 7 months indicated that his language was extremely limited. Thus, the submitted documentation does not establish that the patient has derived a significant benefit in the development of his language skills from RDI. Furthermore, a review of the medical literature revealed a lack of independent studies on RDI and clinical evidence to support the efficacy of RDI interventions. Per the documentation submitted for review, the patient has received several years of RDI therapy without significant benefit. Therefore, based upon the medical literature cited above and the documentation submitted for review, the medical necessity of the requested services has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Crestor 5 mg per day for the treatment of her hypertension and high-sensitivity C-reactive protein. Findings:  The physician reviewer found that the presence of an elevated CRP is indicative of additional coronary risk. In patients with elevated CRP, aggressive LDL lowering (less than 70 mg/dl) has been recommended in selected patients with hyperlipidemia. Crestor has been recommended for this patient as a lipid lowering agent. There are several clinically acceptable statins which would serve as reasonable alternatives to the disputed medication, and there are no randomized controlled trials to suggest the superiority of Crestor in this patient subgroup. The alternative therapy offered by the Health Plan is clinically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested residential treatment services the enrollees polysubstance dependence, major depressive disorder, and parent-child relational problem.  Findings:  The physician reviewer found that this patient had extreme risks factors for relapse, which was recognized by the treatment team. However, she was prematurely discharged and relapsed. Her history is that of extreme maladaptive behavior, severe substance abuse, feelings of alienation from her family and very poor compliance with treatment. Her lack of a supportive home environment coupled with her history of poor compliance with treatment demonstrate the medical necessity of the close monitoring and supervision provided in a 24-hour RTC facility. Consistent with these findings, the services provided during the said timeframe were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested insertion of a lumbar artificial disc for treatment of his medical condition.   Findings: The physician reviewer found that this patient presents with chronic back pain and vague lower extremity symptoms. He has no symptoms or signs of a lumbar radiculopathy with matching dermatomal and myotomal symptoms and findings (Ropper and Zafonte). In addition, there is a lack of documentation that he has failed conservative management including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), pain management, or injections. Moreover, the records do not include a detailed physical and neurologic examination showing orthopedic and vascular causes for the patients pain have been ruled out. He has no evidence of recurrent disc herniation with imaging correlating with his history and examination and there are no signs or symptoms of spinal stenosis or neurogenic claudication. All told, the requested insertion of a lumbar artificial intervertebral disc is not medically necessary for treatment of this patients chronic back pain.Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in neurological 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.