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 a MitraClip procedure with a one-day hospital inpatient stay. The U.S. Food and Drug Administration (FDA) approves the use of percutaneous mitral valve repair using the MitraClip device for high-risk patients with degenerative or other primary mitral valve regurgitation. Asch and colleagues report that the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial demonstrated that patients with 3+ or 4+ mitral regurgitation who remained symptomatic despite maximally tolerated guideline directed medical therapy benefited from MitraClip implantation, regardless of their degree of left ventricle (LV) dysfunction, LV dilatation, pulmonary hypertension, severity of tricuspid regurgitation, or individual mitral regurgitation characteristics. The American Heart Association (AHA) and American College of Cardiology (ACC) guidelines for the management of patients with valvular heart disease recommend the MitraClip treatment for severely symptomatic patients, rated at New York Heart Association (NYHA) class III or class IV, with chronic severe primary mitral regurgitation with favorable anatomy for the repair procedure, a reasonable life expectancy, and prohibitive surgical risk due to severe comorbidities who remained severely symptomatic despite optimal medical therapy. In this case, notes dated 10/6/21 reported that the patient is experiencing severe dyspnea on exertion which is progressive, indicating that the patient has class III heart failure symptoms. Therefore, the requested MitraClip procedure with a one-day hospital inpatient stay is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MitraClip procedure with a one-day hospital inpatient stay is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for the treatment 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 cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

A 35-year-old female enrollee has requested a lumbar discogram for an evaluation of her failed back syndrome. Findings:  The physician reviewer found that lumbar discography is a last resort, pain-provoking diagnostic test used to assess a patients candidacy for surgery for chronic low back pain that has failed extensive conservative care. This is because the outcome of this surgery is variable, and many studies demonstrate no better long-term outcome than extensive conservative care. Therefore, in any patient considering discography, an extensive diagnosis-specific, active physical rehabilitation program with pain control through NSAIDS and analgesics is the well-known standard of care prior to consideration for discography. This patient has not undergone adequate conservative treatment protocols since the hemi-laminectomy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old female has requested  attachment therapy and functional magnetic resonance imaging for evaluation and treatment of her alcohol effects syndrome, bipolar disorder, attention deficit/hyperactivity disorder, and developmental delay.Findings:  The physician reviewer found that at this time, functional magnetic resonance imaging is not part of the standard armamentarium utilized by clinicians, nor is it recommended by reference texts or endorsed in current practice guidelines.  The efficacy of the requested study has not been established in this clinical setting.  The data yielded from functional magnetic resonance imaging is not likely to impact treatment decisions, as particular findings do not yet correlate with specific interventions.  Regarding therapy needs, this patient requires treatment for likely reactive attachment disorder and possible post-traumatic stress disorder.  Conceptually, such therapy is based on abreaction, context and correction, along with the establishment of parental figure consistency in a safe community setting.  This process can take years.  However, the particular modality of attachment therapy is not supported as an evidence-based therapeutic intervention.  Thus, the requested attachment therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested for Apligraf application surgery for treatment of his wound. Findings:  The physician reviewer found that there were no indications of technical reasons for the failure. In light of the patients treatment history, the likelihood of success following a repeated application of Apligraf is quite low. There is inadequate support in the medical literature for repeat application of Apligraf in the setting of prior failure for non-technical reasons.
Appeal type: Urgent Care
Decision: Upheld

The parent of a four-year-old female enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that the patient in this case had been vomiting for several days. She had been evaluated the same day by her primary care provider. Her condition had not suddenly changed prior to her arrival in the Emergency Department. The medical records indicate that the patient appeared well. During the three hours she was observed, no emesis was noted. The patients symptoms were not acute in onset and were not such that a prudent layperson would have sought immediate medical attention for the patient.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested CPT code 14061 (adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips), CPT 30520 (septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), CPT 30140 ((50); submucous resection inferior turbinate, partial or complete, any method), and CPT 11954 (subcutaneous injection of filling material) for treatment of his post-surgical complications.  Findings:  The physician reviewer found that the procedures to the upper lip including cheiloplasty (14061 and 11954), revision of the vermilion, creation of the philtral column, and oral commissureplasty are reconstructive in nature and medically necessary to restore this patients upper lip form and function. The lip and oral commissure are considered abnormal secondary to melanoma resection. The excessive tissue could interfere with his speech and chewing and these procedures would address this functional problem. From the records, the septoplasty and turbinectomy (30520 and 30140) are not reconstructive in nature and not medically necessary for treatment of the patients medical condition. The septoplasty and turbinectomy are not related to the melanoma treatment or resection. In addition, there is a lack of documentation of a functional problem such as a deviated septum, nasal airway obstruction, and turbinate hypertrophy. Further, the photographs do not show obvious nostril deformity, nasal vestibule obstruction, or deviated septum.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female has requested weekly or bi-weekly individual therapy services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that review of the submitted clinical information does not demonstrate that weekly or bi-weekly individual therapy services are medically necessary. Though medications alone cannot be the mainstay of her treatment because of issues related to tolerability of side effects, small group therapy sessions are likely to keep the patient stable and prevent deterioration. Since small group therapy sessions will serve the necessary therapeutic function, one to one weekly or bi-weekly individual sessions are not required.
Appeal type: Urgent Care
Decision: Overturned

A 53-year-old male enrollee has requested for services provided by an out of plan/out of country provider on an urgent basis. Findings:  The physician reviewer found that out of plan emergency services are those obtained from an out of plan provider due to the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. Urgently needed services are those obtained due to an unforeseen illness or injury while traveling outside ones service area, when it would be unreasonable to delay services until a patient can return to his service area. This patients attacks of biliary colic and pharyngitis as well as the outbreak of herpes simplex were all due to unforeseen illness. The patient was suffering from chronic cholecystitis, and he had a dilated common bile duct, which raises the question of bile duct obstruction. Although he was not experiencing acute cholecystitis at any time, there was potential for him to develop total biliary obstruction and eventual cholangitis or pancreatitis. It would not have been prudent for him to travel the distance from Bolivia to California on a commercial aircraft until this situation had resolved. The cholecystectomy was urgently required, and the patient could not wait to return to his service area for this service. Cardiology clearance was required preoperatively on an urgent basis.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for requested Adderall ER 20 mg capsules (dextroamphetamine-amphetamine extended release 20 mg capsules) taken as one capsule twice daily (quantity 60 capsules per month). In this case, the patient has a longstanding diagnosis of attention-deficit/hyperactivity disorder (ADHD) that has been treated with a psychopharmacological medication, Adderall ER, dosed at 20 mg twice daily. The records document that the patient has been stable on this dose and without any side effects for several years. As noted in the peer-reviewed medical literature, stimulants are considered first-line treatment options for patients with ADHD. Per the U.S. Food and Drug Administration (FDA) approval, the maximum dose of Adderall ER daily is 60 mg per day. Although a dose of 20 mg daily of Adderall ER is the standard recommended dosage, treatment guidelines indicate that dosing should be tailored to each patients needs and their response to the medication. Adderall ER has a duration of action from 10 to 12 hours, which is inadequate for many patients. The records establish that this patient has been titrated to a dose of 20 mg twice per day as the lowest effective dosage established more six years ago and continues to benefit without any adverse effects. For these reasons, the requested Adderall ER 20 mg capsules (dextroamphetamine-amphetamine extended release 20 mg capsules) taken as one capsule twice daily (quantity 60 capsules per month) is 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 Adderall ER 20 mg capsules (dextroamphetamine-amphetamine extended release 20 mg capsules) taken as one capsule twice daily (quantity 60 capsules per month) is 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 medication dosage 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old male who sustained a fall in July 2005 with resultant bilateral calcaneal/lumbar fracture. He was hospitalized then transferred to skilled nursing care in August 2005. Once there, he received extensive physical and occupational therapy. The patient was ultimately discharged in December 2005. The Health Plan denied coverage for skilled nursing facility services as of October 2005 on the basis that continued services were not medically necessary.Review of the submitted medical documentation indicates the patient no longer required a level of skilled care services as of October 2005. He was stable for outpatient physical therapy at that time. He no longer required wound care after September 2005. The physical therapy notes state the patient completed his initial goals as of September 2005 and was re-evaluated on October 2005 with new goals established including improved transfer, increased balance and increased gait capacity. A physical therapy notation from October 2005 indicates the patient had made significant progress in all balance and functional mobility activities. He was described as independent of gait throughout and continued to fatigue quickly with steps. The patient was medically stable and able to perform all transfers, toileting and showers independently. As such, continued skilled nursing facility services were not medically necessary or indicated as of October 2005. Based upon the information set forth above, I have determined the services at issue were 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 63-year-old female requesting authorization for bariatric surgery without meeting the Health Plans weight loss requirement. In December 2004 her weight was 234.7 pounds with a body mass index of 41.5. The Health Plan required a 10% weight loss which established a goal weight of 211 pounds for authorization of weight loss surgery. After cessation of smoking, the patient gained additional weight and now must lose 49 pounds. The patients co-morbid conditions include obstructive sleep apnea, hypertension, osteoarthritis and depression. She has completed a psychological evaluation and was deemed a good candidate for weight loss surgery. The patient has requested authorization for bariatric surgery based on a modified preoperative weight loss requirement. The Health Plan denied her request indicating bariatric surgery without meeting the weight loss requirement is not medically necessary.With a BMI of 41.5 (now 46) and comorbid conditions such as obstructive sleep apnea, hypertension, osteoarthritis and depression, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for her. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.  Additionally, there is no data supporting the premise that preoperative weight loss improves outcomes. The psychological evaluation indicates the patient is an appropriate candidate for the surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested coverage for past hospitalization services provided at Contra Costa Regional Medical Center.  The Health Plan has denied this request indicating that the services at issue were out-of-plan post-stabilization care.  Findings:  The physician reviewer found that the presentation of acute leukemia includes symptoms of relatively short duration, including fever, fatigue, and bleeding.  In this patients case, she was appropriately treated in the emergency department.  However, based upon the submitted medical records, the patients emergency medical condition stabilized on the date at issue.  Additionally, the medical records do not demonstrate any periods of destabilization from the date at issue through the remainder of the patient's stay.  This patient was hemodynamically stable and appropriate for transport to an in-plan facility for inpatient level of care services following the emergency department evaluation.  She had no evidence of purpura or petechiae.  Her absolute neutrophil count was 300, but there was no overt source of infection.  This patient had no evidence of gum hypertrophy or bone and joint pain, and there was no evidence of active bleeding.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of gastric bypass surgery for the treatment of diabetes, hypertension, painful joints and sleep apnea, due to obesity.  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 procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Budesonide (9mg daily). The enrollee has a history of inflammatory bowel disease, a perianal fistula, and concern for Crohns disease. A progress note reports the plan from the prior visit was to start prednisone, Uceris and Stelara, but the enrollee did not follow this regimen. The progress note indicates the enrollee had tapered off the prednisone; however, his symptoms returned and prednisone, 15 milligrams was restarted. The enrollees physician reports the enrollee has tried Remicade, Entyvio, methotrexate and Imuran without relief. The note reports the enrollee has shown improvement in rectal bleeding since starting budenoside; however, his symptoms of diarrhea and frequent bowel movements, though improved, continue to be demonstrated. Treatment for four months with budesonide is reasonable and would be considered induction rather than maintenance.  Maintenance would be chronic and lifelong treatment.  This is a request for four months and is appropriate in the professional society guidelines.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested trigger point injections for treatment of the enrollees plantar fasciitis and neuroma. Findings: The physician reviewer found that the enclosed information and pertinent medical guidelines support the medical necessity of the requested trigger point injections for treatment of this patients medical condition. It is well documented in the enclosed progress notes that this patient presents with pinpoint palpable pain to bilateral heels at the plantar fascia origin. Pinpoint palpable pain is also noted to the third interspaces in both feet. The current medical literature and standard of care supports the use of localized cortisone/steroid injections to symptomatic painful areas in this clinical setting. This is especially appropriate given the patients painful proximal plantar fasciitis and Mortons neuroma. All told, the requested trigger point injections are medically necessary for treatment of this patients plantar fasciitis and neuroma.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 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 31-year-old male enrollee has requested adult substance abuse inpatient sub-acute/residential treatment center rehabilitation for treatment of his behavioral health condition. Findings:  The physician reviewer found that the patient reported that he used alcohol on the day of admission. Since the patient used alcohol on the day of admission and due to monitoring for withdrawal with a detoxification protocol, the 10-day inpatient stay was reasonable and medically necessary. However, the medical necessity for inpatient level of care is not evident. The medical records indicate that he was doing well, with no depression or anxiety reported, and he was participating well in group sessions. There were no major findings on a mental status exam (MSE), or any major medical issues. His functional impairment was not in the severe range, and co-morbidity issues were not major; he remained motivated and cooperative during treatment. Based on Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) guidelines, the patient was a candidate for a range of intense treatment interventions at a less restrictive level of care than inpatient sub-acute/residential.