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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for dental surgery procedure (CPT code 41899).Findings:  The physician reviewer found that the medical literature supports the use of general anesthesia in this clinical setting. General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice.  General anesthesia is often employed to facilitate extensive dental treatment, particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting.  In a study by Bader and colleagues, the authors evaluated pediatric dental patients between June 2011 and December 2012, who received general anesthesia. The most common indication for general anesthesia was the childs inability to cooperate and undergo dental treatment under local anesthesia. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for some pediatric patients.  Treatment can usually be completed in one procedure. This patients medical records demonstrate that she requires extensive dental work. The records also noted that this patients providers had determined that local anesthesia would not benefit this patient due to her medical diagnoses. 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 anesthesiology 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 patient is a 35-year-old woman with new onset of headache and facial pain in March 2006. Records from June 2006 indicate the patient had breakthrough pain on Neurontin 3000mg a day and Topamax 150mg a day. Neurontin was initially beneficial but lost its effectiveness. The patient had an allergic reaction to Tegretol. She was initially on Klonopin without documented benefit. As of June 2006 the patients pain was worse and she was evaluated for gamma knife radiosurgery for trigeminal neuralgia. The pain description by the treating neurologist suggests the pain eminates from the occipital region into the temporal parietal region with some involvement of the eye. There was no mention by her treating neurologist of a trigger point in the cheek.At issue is whether gamma knife radiosurgery is medically necessary for treatment of the patients condition.The patients head and facial pain syndrome as described is very atypical for trigeminal neuralgia, as is the patients age. Upon review of the submitted records, the diagnosis of classic trigeminal neuralgia is not confirmed. Rather, the presence of pain in the occipital region and temple as well as the eye suggests this may represent chronic paroxysmal hemicrania or possibly SUNCT syndrome (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing). There is no mention of autonomic symptoms involving the eye.In the absence of convincing evidence of trigeminal neuralgia, gamma knife radiosurgery is not medically necessary. Other possible causes of the patients symptoms should be ruled out. A trial of indomethicin would help establish or refute a diagnosis of chronic paroxysmal hemicrania; if this condition were to be ruled out, a trigeminal nerve block would be appropriate and might help determine if the source is the trigeminal nerve.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees severe receptive and expressive language impairment. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested speech therapy in this patients case.  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.  As noted by the authors, 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 reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, she demonstrates severe receptive and expressive language deficits that negatively impact her ability to achieve age-appropriate functional speech and language skills.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

A 62-year-old female has requested coverage for past urgent care services provided.  Findings:  The physician reviewer found that the patient presented to an urgent care facility complaining of pain in her lower abdomen, burning pain with urination, and visible blood in her urine. Her symptoms had begun the previous day. Her vital signs were normal. The patient rated her pain at 8 out of 10 on the pain scale. Upon evaluation, the patients history did not include fever, flank pain, nausea, vomiting or diarrhea; however, a previous history of kidney disease was noted. Physical examination revealed suprapubic pain to palpation. Urinalysis was positive for leukocyte esterase and blood, findings most compatible with acute hemorrhagic cystitis - a urinary tract infection (UTI). The patient was diagnosed with a UTI with dysuria and given prescriptions for ciprofloxacin to treat the infection and phenazopyridine to treat the pain. She was discharged from the urgent care facility with instructions to follow-up with her primary care provider in two to three days as needed.At issue in this case is whether a prudent layperson in the patients circumstances 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.Review of the submitted documentation demonstrates the patient had severe pain (8/10) associated with symptoms most likely representing an infection of the urinary tract. As noted above, the presence of severe pain is considered an appropriate indication for seeking immediate medical attention. Additionally, the patient had a history of pre-existing kidney disease which could have been subject to worsening in the presence of an untreated urinary tract infection. All told, a prudent layperson in this situation would have thought that immediate medical attention was necessary to prevent serious deterioration of health or complication of an existing medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested electro-acupuncture for the treatment of her neurodegenerative condition. Findings:  The physician reviewer found that the acupuncture treatment notes do not indicate any significant improvement in the patients symptoms. Her neurologist referred her to another acupuncturist who specializes in MS, but the patient apparently wanted to continue the electro-acupuncture treatments. The most recent progress note indicates that patient is `still getting headaches` and had soreness in the head, neck and low back areas and sensitivity in the shoulders and upper back. Correspondence from the patients neurologist, stated the patient 'reported having acupuncture and other treatments with an acupuncturist but did not think it was helping her.' Although acupuncture can be beneficial in reducing headaches and musculo-skeletal symptoms, this patient has been treated by two acupuncturists without  even moderate improvement in symptoms per the medical record submitted. It is not clear why the electro-acupuncture treatments were continued and on-going therapy of this nature is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested for Botox injections for treatment of her urge incontinence.  Findings:  Two physician reviewers found that intravesical Botox is currently being evaluated in multiple studies, its use has not yet been established as superior to conventional therapies in the treatment of this patients medical condition. Dowson and colleagues evaluated patients with bladder oversensitivity refractory to anticholinergics. This randomized, double-blind, placebo-controlled study of 58 patients revealed a significant increase in maximum cystometric capacity (MCC), but this did not translate to clinical benefit with no change observed in the symptoms and quality of life for the majority of patients. In the absence of adequate data demonstrating the safety and efficacy of Botox in this clinical setting, the requested therapy is not likely to be more beneficial than any available standard therapy in managing this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of laparoscopic surgery and participation in an immune therapy program. The Health Plan denied the request indicating that the requested services not medically necessary for treatment of the enrollees pelvic pain.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested laminectomy surgery of the lower back for treatment of the enrollees back pain. Findings: The physician reviewer found that the medical literature supports the use of lumbar laminectomy for patients with spinal stenosis who have failed conservative treatment.  This patient presents with severe axial low back pain radiating into the left posterior leg to the foot with numbness.  The signs and symptoms were consistent with neurogenic claudication. Clinical examination findings correlated with imaging evidence of L1-2, L4-5 and L5-S1 disc herniations with significant central canal stenosis at L1-2 and L5-S1, and reported evidence of nerve root compromise and bilateral foraminal stenosis at L4-5. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. The surgical treatment plans have recommended artificial disc replacement at the L5-S1 level with L4 through S1 posterior spinal laminoforaminotomy and microdiscectomies. Based on the signs/symptoms of neurogenic claudication, imaging evidence of multilevel spinal stenosis, and failed conservative treatment, the requested laminectomy surgery of the lower back is 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 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

A 45-year-old female enrollee requested authorization and coverage of Botox therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power standing system and power seat elevation system for the approved power wheelchair. The submitted documentation does not support the medical necessity of the requested equipment. Toro and colleagues note that there is little data available to support standards development related to independent wheelchair transports. While power seat elevation may assist a user to independently transfer to and from a power wheelchair, the available records do not indicate that this patient would be able to safely perform independent transfers using this feature. The records do not include documentation of any transfer trials. Given that the patients environment may be adjusted to optimize his independence, such as with respect to reach, the requested power seat elevation is not medically indicated. There is a lack of evidence in current medical literature that regular passive standing, such as that achieved with a standing frame, provides clinically significant benefits with respect to muscle function, skin integrity, bone health, respiratory function, digestive function, urinary function or other organ system functions in the setting of severe neurological weakness. In a systematic review of 17 studies, Newman and Barker concluded that while supported standing could prevent small losses of ankle mobility, the clinical importance of these effects was uncertain and low-dose standing was unlikely to protect bone health. A standing frame may mitigate the risk of pressure injuries and wounds but may introduce new areas to the risk of pressure ulcer development, resulting in no clinically significant net gain. While a standing frame may allow the user to interact with nonwheelchair users at eye level, such interaction is not a medical necessity to accomplish mobility-related activities of daily living. Given the lack of evidence showing that the requested equipment results in clinically significant improvement to health and functional outcomes, the requested power standing system is not medically indicated. Therefore, the requested power standing system and power seat elevation system for the approved power wheelchair are not medically necessary to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.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

The patient is a 29-year-old male who carries the diagnosis of upper airway obstructive syndrome which has been interpreted as being mild to moderate.  He is noted to have responded to CPAP at a setting of 9cm H2O during a titration study.   There is no mention of whether or not an actual trial of CPAP was undertaken at home.  The consulting surgeon noted that the patient had an elongated uvula and complained that it gags him at times.  Somnoplasty was recommended and completed.  Procedure notes relate that the soft palate was treated bilaterally and in the midline.  Post-operatively there was marked edema of the uvula, but its excessive length was not addressed in the operative report.  The patient is now requesting reimbursement for the somnoplasty. The Health Plan denied the request based on a determination that the procedure was not medically necessary for treatment of the obstructive sleep apnea.The standard first-line treatment for OSA is a trial of CPAP.  If a patient fails this trial, surgery is then considered.  There is an abundance of literature available regarding the use of radiofrequency ablation for turbinate reduction, tongue base ablation for OSA and soft palate treatment in the setting of snoring.  However, there is no evidence at this time to support the use of radiofrequency ablation of the soft palate as an effective treatment for OSA and the procedure performed did nothing to reduce the length of the patients uvula and so relieve the gagging problem. In addition, it does not appear that the patient has undergone a trial of CPAP.  As such, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 60-year-old female with a history of sporadic but persistent chest pain for 10-12 months. She also reports occasional shortness of breath at the same time but not always. In December 2003, physical examination by the patients provider revealed slight chest wall tenderness on the left and an occasional expiratory wheeze. Cardiac exam showed regular rate and rhythm. It was not noted whether a murmur or click was heard. The patients provider noted the patient had been previously seen by another provider who apparently heard a murmur and found an electrocardiogram to be normal. It appears the enrollees previous provider recommended an echocardiogram for assessment of a heart murmur. The Health Plan has denied authorization and coverage for an echocardiogram on the basis that it is not medically necessary.Based upon the submitted documentation, it appears a murmur was appreciated by one of the patients providers who then recommended an echocardiogram for the evaluation of this patient who also had complaints of shortness of breath and chest discomfort. Evaluation of a heart murmur in patients with cardiorespiratory symptoms is a widely accepted indication for an echocardiogram. Thus, an echocardiogram in this case is medically reasonable and appropriate and is indicated based upon American College of Cardiology guidelines. Therefore, I have determined that the requested echocardiogram is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Overturned

A 33-year-old female has requested coverage for past emergency services.   Findings:  The physician reviewer found that the patient presented to the emergency department with chief complaint of severe left ear pain, fever, difficulty hearing out of the left ear and cough for 14 days. The emergency department triage records indicate the patient began experiencing a fever earlier that day and had severe pain as well as difficulty hearing out of her left ear. The patient reported her pain as a 9 on a scale of 1 to 10. The patients vital signs included temperature 99.9 degrees, pulse 90, respirations 16, and oxygen saturation 100% on room air. The patient was assessed with upper respiratory infection and otitis media left ear. She was prescribed Z-Pak and Vicodin and was discharged from the emergency department.At issue in this case is whether a prudent layperson in the patients circumstances 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.A prudent layperson would have sought immediate medical attention on the disputed date of service due to symptoms including severe ear pain, fever, and cough. The submitted medical records document the patients pain level as 9 on a scale of 1 to 10. Based upon the definition of emergency medical condition stated above, the presence of severe pain is an appropriate indication for seeking immediate medical attention. Further, the absence of immediate medical attention in this setting had the potential to result in serious impairment of hearing, worsening infection and risk for sepsis, meningitis and other infectious complications. All told, the patients decision to seek immediate medical attention was consistent with the response of a prudent layperson in this situation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested the LINX Anti-Reflux procedure for treatment of her medical condition.   Three physician reviewers found that it is not clear that this patient has symptoms related to acid reflux.  This is based on her normal DeMeester score and poor response to acid secretory inhibitory therapy.  The LINX device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing.  The results from early studies at four years are encouraging.  However, controlled data for the procedure are lacking.  The current medical evidence has not demonstrated that the device is more efficacious than fundoplication and whether it has the durability of fundoplication.  All told, the superior efficacy of the LINX Anti-Reflux procedure has not been established.   Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.