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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient stay provided from 3/13/15 through 3/16/15. Findings:  The physician reviewer found that in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The inpatient stay provided from 3/13/15 through 3/16/15 was not necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient presented to the ED with acute abdominal pain and was diagnosed with biliary colic and mild cholecystitis. The patient was stabilized while in the ED and during the surgical consultation. The patient could have been scheduled to undergo an elective cholecystectomy on a later date.  Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. 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 diagnostic molecular pathology (genetic testing) services. Based on the available published peer-reviewed studies and current guidelines, genetic testing to direct individualized treatment was likely the best approach in this patients evaluation and treatment. She was diagnosed with low grade serous ovarian cancer. Her provider recommended germline and somatic tumor testing to better assess and treat the patient. Due to emerging therapeutics for less common ovarian cancers, including low grade serous ovarian cancer, there is value in identifying potential pathways for treatment options and for potential clinical trial recruitment. Given this patients diagnosis of ovarian cancer, the genetic testing performed was indicated to help detect mutations and guide treatment. There are limited data in these cancers given their infrequency and it is difficult to acquire prospective data. All told, the diagnostic molecular pathology (genetic testing) services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three of the three physician reviewers found the diagnostic molecular pathology (genetic testing) services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in genetics 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested a real-time remote heart monitor for medical treatment of her palpitations.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options.  In this circumstance, if further evaluation for dysrhythmias is indicated the off-line self-activated event monitoring would be sufficient in recording cardiac rhythm during palpitation symptoms. In addition, off-line auto-triggered event recorders are effective in identifying asymptomatic paroxysmal dysrhythmias. There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Based on the documentation submitted for review, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 13-year-old enrollee has requested somatropin growth hormone (GH) therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that the records provided for review do not demonstrate that this patient has classic GH deficiency, as he had a normal result on GH provocative testing, and his IGF-1 level is normal for bone age. He has no known morphological abnormalities of his pituitary gland and no biochemical evidence of pituitary hormone deficiencies. Based on the patients height and bone age, his estimated final adult height is just over 65 inches, which is appropriate for his genetic potential and within normal limits for U.S. adult males. The most likely reason for a fall-off in height is constitutional delay. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor binding protein 3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet these criteria based on the records provided for review. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the delivery of the enrollees unborn child at a tertiary hospital that has a level III or level IV neonatal intensive care unit (NICU) equipped with extracorporeal membrane oxygenation (ECMO) system. The Health Plan has denied this request indicating that the requested services are not medically necessary for delivery of the enrollees unborn child.Findings: Congenital diaphragmatic hernia (CDH) occurs in one out of 2500 live births and is characterized by incomplete closure of the diaphragm, usually on the left side, which allows abdominal organs to enter the chest, pushing the heart to the right and compressing the lungs.  This can lead to pulmonary hypoplasia and impaired oxygenation at birth.  The degree of pulmonary compromise can be predicted by the lung head ratio.  Patients with ratios less than 1 have the worst prognosis and the greatest risk of need for ECMO.  ECMO has been shown to improve survival in CDH patients who are most severely affected. However, systematic reviews are unclear as to the benefits of ECMO in treating CDH patients with less severe prognosis. In this case, the documentation indicates this patient has a relatively good prognosis. Additionally, the consultation record indicates that delivery can be safely performed at a level III neonatal intensive care unit even if they do not have ECMO available. In sum, the delivery of the patients unborn child at a tertiary hospital that has a level III or level IV NICU equipped with ECMO system is not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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 55-year-old female enrollee has requested a colonoscopy for evaluation of her polyps.  Findings:  The physician reviewer found that it is medically reasonable and appropriate for the patient to undergo a colonoscopy at this point in time. The patient has a family history of cancer and a family history of polyps, both in a first degree relative. As such, a colonoscopy is medically prudent and indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for brand name Advair Diskus purchased on early of 2021 and prospective authorization and coverage for brand name Advair Diskus. The submitted documentation supports the medical necessity of the medication at issue. Papi and colleagues noted, The goal of asthma treatment is to achieve good asthma control such as to minimize symptom burden and risk of exacerbations. Advair (fluticasone propionate-salmeterol) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of asthma. This medication is included in professional treatment guidelines for the management of asthma. Advair should be used for patients not adequately controlled on a long-term asthma control medication. (U.S. Food and Drug Administration). In this case, the patient has already tried Advair in the past, and demonstrated a positive treatment response with sustained asthma control. Records on early of 2021 state that the patient developed increased asthma symptoms when she switched to Wixela. Therefore, the brand name Advair Diskus purchased on early of 2021 was medically necessary for the treatment of the patients medical condition. Additionally, the requested future brand name Advair Diskus is medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification in pulmonary disease 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 10-year-old female enrollee has requested speech therapy for the treatment of the enrollees speech deficits. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has benefited from speech therapy in the past and experienced regression after the therapy was discontinued. Based on the evidence provided, speech therapy should be resumed to prevent further relapse. The patient should receive speech therapy for a six-month period. The patients therapist should establish specific goals and evaluate progress toward those goals. At the end of the six-month period, the patient should be re-evaluated to determine if continued therapy is indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sildenafil 20 mg tablets taken three times a day for 90 days for a total of 270 tablets. This patients records support a diagnosis of limited cutaneous scleroderma associated with CREST syndrome with calcinosis, esophageal dysmotility, telangiectasias and Raynauds syndrome, but not systemic sclerosis. The records report that she did not respond to nifedipine and antiplatelet therapy. However, the patient does not have documented pulmonary artery hypertension, for which sildenafil would be indicated. In addition, she has been responsive to current medications and also has not tried and failed other standard therapies such as Prazosin or Cozaar. Vitiello and colleagues noted that the initial approach in treatment is vasoconstriction can be reduced by avoiding precipitating factors, such as cold, stress, and nicotine. The use of topical antibiotics and occlusive dressings (hydrocolloid) can promote healing, but the choice of dressings depends on the presence or absence of underlying infection. The author reported that treatment might include calcium channel blockers angiotensin II receptor blockers such as Losartan, a blocker such as Prazosin and selective serotonin reuptake inhibitor such as Prozac. Based on the available records, the patient has not exhausted all other possible therapies and is thus, not considered refractory. All told, the requested sildenafil 20 mg tablets taken three times a day for 90 days for a total of 270 tablets is not medically necessary for 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 rheumatology 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 a heavy duty 3 or 4 wheeled scooter for treatment of her cerebral palsy. Findings:  The physician reviewer found that the requested equipment is not medically necessary for treatment of the patients medical condition. Auger and colleagues reviewed the outcomes of power mobility devices for middle-aged and older adult users. The authors noted that Most of the research designs were assigned very low evidence grades. Although power mobility can benefit specific individuals, it is not likely to be of benefit in this clinical setting. In this case, the patient has a mild personal mobility deficit and is a functional household ambulatory and she has a caregiver to assist her. She is unable to use a power or manual wheelchair. Additionally her abode cannot accommodate a power device. A transport chair, not a power scooter has been recommended. A power scooter is not medically necessary to safely maximize the patients independence. Accordingly, the request for a heavy duty 3 or 4 wheeled scooter has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 with sub-specialty certification in neuromuscular 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: Upheld

A 60-year-old male has requested coverage for Egrifta Tesamorelin Acetate 1 mg, for injection for treatment of his HIV related lipodystrophy.  Findings:  The physician reviewer found that lipodystrophy is an abnormal accumulation of fat. Currently, as stated in the press release from the FDA, Egrifta has been demonstrated to decrease abdominal fat. However, whether Egrifta decreases the risk of cardiovascular disease or improves compliance with antiretroviral drugs has not been studied. Thus, more clinical study is necessary to warrant a valid conclusion that functional improvement is definitive or maintained with this therapy. Based on the FDA approval, Egrifta may be a strategy to create a normal appearance to the extent possible.  This patients abnormal collection may be caused by the treatment of HIV, which is an infection, but obesity may be a contributing factor as well. Overall, the supporting documentation does not specify the severity and detail of the patients condition. The treating provider only notes on examination that the patient has fat redistribution of the abdomen. The waist-to-hip ratio is documented, which is abnormal, but the patients obesity could also be a contributing factor. All told, there is insufficient medical documentation describing the severity of the patients condition to support the requested therapy as reconstructive in nature or medically necessary for treatment of his medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an implanted hypoglossal nerve stimulator. Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and safety for treatment of OSA. In patients who do not tolerate CPAP, or fail to improve with an oral appliance, surgical intervention may be required. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. As reported in the published medical literature, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. The studies reported the hypoglossal nerve stimulator is safe and effective in patients with OSA who have nonconcentric airway collapse, an apnea/hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. This patient meets the criteria for the requested procedure with nonconcentric airway collapse, an AHI of 33, and BMI of 24. She has failed CPAP and due to the severity of her condition, the patient is not a candidate for oral appliance therapy. For these reasons, an implanted hypoglossal nerve stimulator is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.One reviewer found that an implanted hypoglossal nerve stimulator is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology with subspecialty certification in plastic and reconstrutive surgery and is actively practicing.  One Reviewer is board certified in otolaryngology with subspecialty certification in sleep medicine and is 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the carotid duplex scan for evaluation of the enrollees chest discomfort, hyperlipidemia, dizziness, and a strong family history of coronary artery disease. Findings:  The physician reviewer found that the records provided for review indicate that this patient did not have carotid bruit or focal transient neurological symptoms. Guidelines of the American College of Cardiology (ACC) and other sponsoring organizations do not support the use of duplex ultrasound imaging for dizziness such as recorded for this patient. Given the lack of support for the study in this clinical setting, the carotid duplex scan performed was not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the service at issue was 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 internal medicine with sub-specialty certification in cardiovascular disease 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.