Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

A 22-year-old male has requested coverage for past residential treatment center (RTC) services provided for 27 days.  Findings:  The physician reviewer found that the patient had a previously undiagnosed drug problem consistent with polysubstance dependence. Based upon the documentation provided, he had no prior history of chemical dependency treatment, substance rehabilitation services, detoxification or psychiatric treatment, such as hospitalization, psychotherapy or psychotropic medication management at any level of care. Upon discovery of the magnitude of the patients drug use, his family believed this situation to be an emergency and phoned a substance use crisis line which recommended acute treatment and dispatched an interventionist to the home.  After that meeting, the patient was transported to a residential treatment facility for further treatment. The patient has requested reimbursement for the residential treatment services provided during the dates at issue. 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.A psychiatric emergency may be based on a wide spectrum of biological, psychological, and social problems. Although the cause varies, the common thread among all such emergencies is the requirement of an intervention to avoid permanent harm and prevent unnecessary morbidity and clinical deterioration. Given that the patient and his family did not have previous experience with appropriate treatment protocols in this situation, it would not be unreasonable for a layperson to consider the presenting matter an issue of life or death. Thus, the familys decision to seek emergent care was consistent with the response of a prudent layperson in this situation. However, while the patient was in need of prompt care that included a multidisciplinary treatment plan with well-delineated treatment goals and objectives, by the day following his admission an emergency medical condition, as defined above, no longer existed. On the next day, the patient was not experiencing acute symptoms of such severity that his transfer to another facility or treatment setting was precluded. As such, while a prudent layperson in this situation would have sought immediate medical attention, there is no evidence that the patient was experiencing an ongoing emergency medical condition from the day after the admission through the end of the remaining 26 days.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for IgG food sensitivity testing for evaluation of the enrollee, who has a history of gastrointestinal symptoms. Findings:  Three physician reviewers found that the patient has a history of diarrhea, bloating and weight gain. She was noted to have eliminated wheat from her diet and was doing better with less bloating and diarrhea. The patient had comprehensive metabolic panel, celiac panel, and immunoglobulin G (IgG) test. Her celiac panel was normal and her IgG to wheat was positive.  The patient requests reimbursement for the IgG food sensitivity testing. The Health Plan denied reimbursement for the services at issue. The Health Plan deemed the services at issue as investigational for the evaluation of this patients medical condition. Multiple evidence based studies have demonstrated that IgG testing to foods is an unproven method of testing for food intolerances as well as food allergies. The Guidelines for the Diagnosis and Management of Food Allergy, published by the National Institute of Allergy and Infectious Diseases (NIAID) specifically lists tests that are unproven and non-standardized. IgG food sensitivity testing is not recommended for the diagnosis of food allergy. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not the disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or food intolerance. Moreover, there has been a lack of evidence to support that IgG antibodies cause symptoms. All told, testing for wheat IgG is not a standardized or recommended method of evaluating and treating patients who are suspected of having food allergy or food intolerance.  Therefore, the IgG food sensitivity testing performed was not likely to be more efficacious than the standard modalities of evaluating this patients medical condition. Final Result: The reviewers determined that the services at issue were 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 reviewers are board certified in allergy and immunology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that the American College of Radiology (ACR) urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging only. Therefore, 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 physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 CDx genetic testing. Understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next-generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment. In this patients case, the records document that Foundation One testing was previously performed. Thus, Guardant360 CDx genetic testing was not indicated. Both tests were not needed in this patients case. Therefore, Guardant360 CDx genetic testing performed by Guardant Health, Inc. was not likely to have been more beneficial than any available standard treatment for the patients medical condition.Findings: Two out of three medical experts decided that Guardant360 CDx genetic testing performed by Guardant Health, Inc. was not likely to have been more beneficial for the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is 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

A 47-year-old female enrollee has requested coverage for lumbar spinal fusion surgery. The Health Plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees spondylolisthesis at L4-5 and degenerative disc disease.   Findings:  The physician reviewer found that in the medical literature and Milliman Care Guidelines, the clinical indications for spinal fusion include moderate to severe lumbar spinal stenosis associated with lumbar spondylolisthesis or with evidence of spinal instability, either pre-existing or anticipated due to the need for bilateral decompression or wide decompression involving facetectomy or resection of the pars interarticularis. In addition, spondylolisthesis with progressive deformity or neurologic compromise with persistent and significant symptoms despite an adequate trial of non-operative care may also require fusion. In this case, the patient has spondylolisthesis stenosis with evidence of instability. Therefore, the requested fusion and instrumentation is indicated by both pre-existing and probable iatrogenic instability. With supporting medical evidence for the role of fusion in this patients medical condition, the requested surgery has been demonstrated to be medically necessary.
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 right and left foot for evaluation of the enrollees bilateral neuroma. Findings:  The physician reviewer found that the requested diagnostic magnetic resonance imaging (MRI) is not supported as medically necessary for the evaluation of this patients medical condition. Review of the documentation provided indicates the patient has not failed alternate conservative treatment options including immobilization, off-weight bearing, series of steroid injections, shoe modifications/orthotics, oral anti-inflammatory medications, physical therapy, and has not had a diagnostic ultrasound examination. Therefore, the requested MRI of the right and left foot are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedures 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 podiatry 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 55-year-old female enrollee requested the MiniMed 530G with Enlite (E0784, A9277, and A9276 for medical treatment of her type 1 diabetes.  Findings:  The physician reviewer found that continuous glucose monitoring systems are U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control. In addition, these devices can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, and show early morning spikes in blood sugar (Cheyne and Kerr). Given this patients history of frequent hypoglycemic episodes, the requested MiniMed 530G pump with Enlite continuous glucose monitoring system is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with limb-girdle muscular dystrophy. The provider noted that the patient has increasing ventilatory insufficiency and inability to transfer and reposition herself due to complete immobility. Additional noted concerns included the patients risk for recurrence of sores. The patients neurological examination was consistent with severe weakness. A durable medical equipment (DME) evaluation revealed the patients active range of motion in the lower extremities is not functional, and only 25% in the upper extremities. In addition to limb-girdle muscular dystrophy, the patient has a medical history of fractures.Findings:  The physician reviewer found that limb-girdle muscular dystrophy is a progressive form of degenerative muscle disease. This patients records document that due to this condition, she is nonambulatory, with reduced strength in her arms and significant weakness in her legs. The patients physical weakness decreases her ability to change positions in bed and operate manual bed cranks.  The decreased mobility increases the propensity for pressure ulcers. The requested equipment is likely to decrease adverse medical events as well as improve the patients mobility and quality of life. The documentation supports that the total electric hospital bed with alternating pressure mattress and side rails is medically necessary. Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan, positron emission tomography (PET) scan, biopsy and pathology for evaluation of the enrollees neck pain, hearing loss, rhinitis, and nasal polyp. Findings: The physician reviewer found that the medical literature, PET/CT imaging can have a substantial impact on intended management when used for three targeted diagnostic indications: (1) determining whether a suspicious lesion is cancer; (2) detecting an unknown primary tumor site in a patient with confirmed or strongly suspected metastatic disease; and (3) detecting a primary tumor site in a patient with a presumed paraneoplastic syndrome. PET/CT plays a crucial role in the diagnosis and management of patients with head and neck squamous cell cancer (HNSCC). The major clinical applications of this method include diagnosing an unknown primary tumor, identifying regional lymph node involvement and distant metastases, and providing prognostic information. In addition, PET/CT can be used for precise delineation of the tumor volume for radiation therapy planning and dose painting, and for treatment response monitoring by detecting residual or recurrent disease. This patient has been followed for GERD and recurrent H. Pylori infections. His symptoms include a burning taste but there was no documentation of dysphagia or hoarseness or difficulty with speech, which are common in head and neck cancers. Moreover, there was no documentation of constitutional symptoms suggesting tumor burden. He has been evaluated with more than one nasopharyngoscopy and EGD, and although there have been findings of arytenoid edema which is suggestive of GERD and diffuse gastritis, no mucosal abnormalities suggestive of tumor infiltration or mass effects have been described. Prior imaging has been negative. Finally, there is no documentation of cervical lymphadenopathy to suggest an unknown primary tumor. 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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 23-month-old female born the product of twin gestation delivery with an apparent perinatal or natal anoxic event possibly associated with an occlusion of the cord. MRI is within normal limits. Vision is intact, speech is delayed. The patient has been diagnosed with cerebral palsy with spastic quadriplegia and truncal hypotonia. She has been receiving occupational and physical therapy and has made slow gains with trunk control. The patients therapists are recommending a TheraTog garment to improve trunk control.I have reviewed the literature provided by the vendor for justification of the TheraTog garment. Most of the literature is small scale, case study on review literature, which is not evaluating treatment in hypotonia, but rather, hypotonia in the upper extremities. The only hypotonia noted is fisting of the patients hands. The article cited by the patients providers as a key reference reports the garment was abandoned by all but one of the families. Furthermore, the study does not describe the specific use of the garment.Given the lack of scientific evidence, it cannot be determined that the requested equipment is medically necessary for this patient. As the Health Plan is not required to cover this equipment the patients providers may want to attempt to have the regional center purchase the equipment.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested BRCA genetic testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that per the National Comprehensive Cancer Network (NCCN) guidelines BRCA testing is indicated for an individual that has been diagnosed with breast cancer at any age and at least one first degree family member diagnosed at the age of 50 or younger. This patient meets criteria for BRCA testing per NCCN guidelines. Thus, BRCA genetic testing 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 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:  All three reviewers are  board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoscopic revision of gastrojejunal anastomosis (CPT code 43999) and anesthesia (CPT code 00731). Thompson and colleagues studied the safety and efficacy of transoral outlet reduction for the treatment of weight regain in Roux-en-Y gastric bypass patients. Weight loss or stabilization was achieved in 96% of patients six months after outlet reduction. Researchers noted, When implemented as part of a multidisciplinary intervention, transoral outlet reduction using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after Roux-en-Y gastric bypass surgery. In this case, the patient has coronary artery disease requiring intervention at a young age. Due to the anatomic defect of a dilated gastrojejunal anastomosis, she is now at risk for weight regain after Roux-en-Y gastric bypass. As medications for weight loss are no longer usable in her case, she is at risk for recurrence of weight regain. This can re-institute the cardiac risks of obesity that had been reduced by the Roux-en-Y gastric bypass. Given the patients history of coronary artery disease requiring intervention, weight regain after Roux-en-Y gastric bypass in the setting of anatomic defect (dilated gastrojejunal anastomosis), and now inability to continue medications for weight loss, endoscopic revision of gastrojejunal anastomosis (CPT code 43999) is supported as medically necessary to address the anatomic defect leading to weight regain in this case. The request for anesthesia (CPT code 00731) care is also supported. The American Society for Gastrointestinal Endoscopy recommends monitored anesthesia care for prolonged procedures requiring deep sedation. As endoscopic revision of gastrojejunal anastomosis (CPT code 43999) requires endoscopic suturing and is a complex and prolonged procedure, the medical necessity of anesthesia (CPT code 00731) care is supported in this case. Therefore, endoscopic revision of gastrojejunal anastomosis (CPT code 43999) and anesthesia (CPT code 00731) are medically necessary 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 internal medicine with sub-specialty certification 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.