Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Spinraza (nusinersen) for treatment of the enrollees spinal muscular atrophy. Findings:  Three physician reviewers found that spinal muscular atrophy is a rare autosomal recessive disorder characterized by muscle atrophy and weakness resulting from motor neuron degeneration in the spinal cord and brainstem. Spinraza has been approved by the U.S. Food and Drug Administration for intrathecal use in pediatric and adult patients with spinal muscular atrophy. Studies show improvement in motor function across spinal muscular atrophy of all types. This medication has been found to be safe and well-tolerated across all age groups studied. There is a lack of other treatments available. Final Result: The reviewers determined that the requested medication is 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: Reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an enrollee has requested reimbursement for air and associated ground ambulance transportation.In order to be medically necessary, air ambulance transportation must meet the following criteria: the individuals condition must be such that any form of transportation other than ambulance would be medically contraindicated; the individuals condition is such that time needed to transport by ground poses a threat to the patients survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital does not have the required services and facilities to treat the patient.In this case, the patient sustained a severe, acute traumatic brain injury without other significant concomitant injuries associated with long-term functional sequelae. The patient received critical care services in the early aftermath of the injury and was eventually stabilized sufficiently for rehabilitation-focused care. Due to the severity of the patients deficits and the intensity of his rehabilitative needs, he did require inpatient rehabilitation services. There was, however, no medical necessity for the patient to be transferred by air ambulance from the acute hospital in California, the first facility, to an out of state rehabilitation facility on the date of service. The patient could have been transported via a ground ambulance to an appropriate inpatient rehabilitation facility that was in closer geographic proximity to the originating acute hospital in California. This ground ambulance could have been equipped/staffed with the appropriate crew and support services that the patient needed in transit. No clinically or functionally significant difference in the patients long-term outcomes at an appropriate geographically proximate rehabilitation facility would have been reasonably expected in comparison to his outcomes following rehabilitation at the out of state facility to which he was transferred. Criteria for air ambulance transport were not met in this case. Therefore, air and associated ground ambulance transportation provided on the date of service were not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SPRINT peripheral nerve stimulation (PNS) system. Findings:  The physician reviewer found that presents with chronic low back that is not associated with radiation. He has evidence of mild degenerative disc disease at L4-5 and L5-S1 without signs of high-grade canal or foraminal stenosis. Previous treatments have included non-opioid analgesics, exercises, trigger point injections, and epidural steroid injections, with some relief. The patients records do not report treatment with lumbar medial branch blocks or radiofrequency ablation procedures. The patient has requested treatment with PNS. The current studies assessing PNS for chronic low back pain are limited, with a lack of high-quality prospective randomized control trials and long-term outcome data. Gilmore and colleagues evaluated nine patients treated with PNS of the lumbar medial branches to treat chronic low back pain. The authors found clinically significant reductions in average pain intensity in 67% of patients compared to baseline with sustained results at one-year follow-up. Kapural and colleagues included two patients in their study and reported that PNS can produce sustained pain relief and reduce or eliminate the need for analgesic medications, including opioids. Given the limited data in the peer-reviewed medical literature, the requested SPRINT PNS system is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested SPRINT PNS system is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is 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 anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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 54-year-old female enrollee has requested X-Stop implantation for the treatment of her spinal stenosis. Findings:  Two physician reviewers found that at this time, there is insufficient data to support the contention that X-Stop implantation is the superior treatment option. Laminectomy is the gold standard for patients such as this patient. No study has demonstrated that X-Stop is more than or as effective as laminectomy, particularly with a two-level procedure.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee requested authorization and coverage of  a repeat myelogram procedure for the treatment of back and leg pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested neck surgery for treatment of her degenerative disc disease. Findings:  The physician reviewer found that in this patients case, there is evidence of disease at multiple levels on x-ray, MRI, and CT scan, and there is a lack of evidence of localization of the level of origin of the symptoms. The electroneurodiagnostic studies performed were not specific, and no other investigation is documented. There is also a lack of documentation of conservative measures other than chiropractic, acupuncture, and epidural steroid injections. Physical therapy is mentioned, but not described as to modality or results. There is no documentation of the use of nonsteroidal medications, or the reasons for not using them.  Based upon the submitted documentation, the medical necessity of the requested neck surgery has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Hybrid Maze procedure and percutaneous transcatheter closure of the left atrial appendage with endocardial implant. Based on the current literature and review of multiple studies, the Hybrid Maze procedure results in reduced arrhythmia recurrence and fewer re-interventions when compared with catheter ablation to treat atrial fibrillation. Researchers reported long-term success with the Hybrid Maze procedure at four-year follow-up. Although there are surgical risks involved with the procedure this patient would likely benefit from this procedure given age and symptomatic arrhythmia episodes despite multiple catheter ablations and antiarrhythmic medications. Therefore, the requested Hybrid Maze procedure and percutaneous transcatheter closure of the left atrial appendage with endocardial implant are supported as likely to be more beneficial for treatment of the 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 internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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

A 62-year-old female enrollee has requested magnetic resonance imaging (MRI) of the face, neck, orbits, and breasts for evaluation of her Merkel cell carcinoma.  Findings:  The physician reviewer found that the PET/CT study that is planned is appropriate given this patients biopsy proven Merkel cell tumor, which is an aggressive tumor known to metastasize. By contrast, there are no records supporting the medical necessity of the requested MRI of the breasts, face, orbits and neck. MRI of multiple body parts may be indicated based on abnormal prior imaging tests or as part of a surveillance protocol for certain tumors. However, there is not enough information given to justify the MRI studies requested of the head, neck, face, orbits and breasts at this time.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 6-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. 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. This patient had developed an earache the day prior to the visit to the emergency department. On the day she was evaluated, the patient complained of a sore throat as well. The family denied any fever or vomiting. Her father reported she had been crying in pain. However, on arrival at triage, the patient appeared well. She was triaged as a level 5 out of 5, the least acute triage level. The physicians records note the patient was in no distress. Her exam was normal. The patient was treated only with oral Tylenol in the emergency department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. Her symptoms were not sudden or acute in onset. The patients symptoms on the date of service at issue did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients parents circumstances would not reasonably have expected the absence of emergency care to jeopardize their childs health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Strattera with a dosage of 40 mg 2 x daily for treatment of her attention and concentration deficit following cerebral infarction. Findings:  The physician reviewer found that the patient presents with poor concentration and inattention following cerebral infarction is more consistent with the diagnosis of major or mild vascular neurocognitive disorder. The patient has a symptom burden similar to attention deficit hyperactivity disorder (ADHD). Strattera is a selective norepinephrine reuptake inhibitor used to treat ADHD. Pharmacotherapy is the first-line treatment for ADHD. The patient has no evidence of arrhythmia or elevated blood pressure. The medication has been conservatively dosed, well-tolerated and reportedly efficacious with no adverse drug response. Thus, continued treatment with Strattera is safe, appropriate and consistent with good medical practice. Final Result: The reviewers 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 psychiatry 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: The patient requested Gel One injections. Findings: The physician reviewer found that requested injections are medically necessary. The submitted orthopedic report documented complaints of bilateral knee pain. Functional limitations were noted in sitting, standing, and walking for prolonged periods of time, and pain interfered with activities of daily living. Bilateral knee X-rays demonstrated severe bilateral osteoarthritis. The diagnosis included severe bilateral medial compartment degenerative and post-traumatic osteoarthritis. The provider recommended the Gel One injections for the patients bilateral knees for primary osteoarthritis. In a meta-analysis of 137 studies with 33,243 participants, hyaluronic acid was found to be better than injected placebo or injected corticosteroids. The meta-analysis concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. In addition, the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis.Evidence-based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with significantly symptomatic osteoarthritis of the knee. Moreover, repeat viscosupplementation has been found to be safe and effective; more effective than corticosteroid injections and allows for delay of total knee replacement. In this case, the patient presents with progressively worsening bilateral knee pain. Functional limitations affecting the ability to perform activities of daily living are noted. There is radiographic evidence of near complete medial compartment joint space narrowing, subchondral sclerosis, and periarticular spurring. The patient failed to adequately improve with activity modification and non-steroidal anti-inflammatory drugs (NSAIDs). Therefore, the requested bilateral knee injections (Gel-One injection) are medically necessary for treatment of the patients medical condition.  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

An 18-year-old male enrollee has requested residential treatment services for his anxiety disorder, not otherwise specified and dysthymic disorder. Findings:  The physician reviewer found that upon admission to the residential treatment center, the patient acknowledged that his drug use was out of control. His history was positive for a psychiatric hospitalization due to psychotic symptoms and substance use. He was involved in outpatient treatment prior to admission to residential treatment. However, he continued to display serious functional impairment. The patient would leave home for days, and there was a pattern of constant uncontrolled use of drugs. He was ambivalent about treatment. Consistent with the American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System, the patient was a candidate for residential level of care.  Previous experiences in treatment at a lower level were unsuccessful. There was severe functional impairment, with a GAF of 35 on admission. There were also significant comorbid issues in addition to mood disturbance, anxiety and a history of psychotic symptoms. Progress notes during the course of treatment indicate that he remained anxious, he continued to have strong cravings and urges to use. He was experiencing increased feelings of sadness. Medication adjustments were necessary throughout his stay. All told, residential treatment services provided were medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard stool testing. Findings:  The physician reviewer found that there is a lack of support in peer reviewed evidence based literature for the superior efficacy of the services at issue when compared to the conventional options of evaluating this patients medical condition. The conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Toward this end, the efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against the gold standard, optical colonoscopy. The records do not document a contraindication by this patient to optical colonoscopy. Given the low sensitivity of Cologuard in detecting adenomas, the assay is not as beneficial as any established alternatives in this patients case. The available records do not support that more effective conventional screening strategies are contraindicated in this patients case.  As such, Cologuard testing was not likely to have been of greater benefit when compared to other methods of evaluating this patients medical condition. Final Result: Two of the three reviewers determined 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested a corrective procedure for his nasal septum for treatment of his status post septorhinoplasty and right endoscopic turbinectomy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  Nasal airway obstruction can lead to sinus infections and may hamper respiratory capacity during exercise or strenuous activity. However, there is no documentation of nasal airway obstruction in this patient after surgery.  Therefore, additional surgery to correct such a condition would not be medically necessary.  All told, the requested corrective procedure for the patients nasal septum is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees inflammatory polyarthropathy. Findings:  The physician reviewer found that per the peer-reviewed evidence based medical guidelines, Otezla is indicated for the treatment of psoriatic arthritis or plaque psoriasis. In the records provided for review, there is no documentation of objective findings that this patient has either of these diagnoses. Currently, there is a lack of scientific data supporting a clinical role for Otezla in patients with inflammatory polyarthropathy. On the basis of this lack of documentation and peer-reviewed evidenced based guidelines, the requested Otezla is not medically necessary for treatment of this patients medical condition. 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

A 52-year-old female enrollee has requested Levaquin 500mg because she was traveling out of the country. Findings:  The physician reviewer found that Fluoroquinolones (e.g., Cipro) are known to cause gastrointestinal upset and sun sensitivity. While diarrhea is a common side effect of all quinolones, bloody or watery diarrhea may be a sign of a serious reaction to these antibiotics that can occur when certain bacteria overgrow in the colon. In this case, there was no documentation of intolerance to Cipro in the patients medical records, and no documentation of culture and sensitivity showing resistance to Cipro. Thus, Levaquin 500mg was not medically indicated for this patient.