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

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for urgent care services provided on 10/6/14 and 10/8/14.  Findings:  The physician reviewer found that at issue 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 urgent care services provided on 10/6/14 and 10/8/14 were not necessary for treatment of an emergency medical condition. In this case, the patient presented on 10/6/14 with abdominal pain for two days. Her vital signs were normal and no other data is available. On the visit 10/8/14, the patient returned to the same facility for her laboratory test results. She reported persistent abdominal pain. She denied any other symptoms such as dysuria, vomiting, or blood in her stool. There were no symptoms to suggest an acute decompensation in the patients condition or an emergency medical condition. Her vital signs and physical exam were normal. The patient refused further evaluation by pelvic exam. The documentation provided does not support that the patients symptoms were acute in onset or severe.  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: Medical Necessity
Decision: Overturned

A 38-year-old male enrollee has requested for Cialis for treatment of his condition. Findings:  The physician reviewer found that Cialis is accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. It is medically appropriate to treat complaints of erectile dysfunction empirically with Cialis. Cialis has no impact on desire or sensation. Thus, this medication would not be reasonably requested by patients who do not have erectile dysfunction. This medications high safety profile in all except those taking nitrates has been established and justifies empiric use. Since erectile dysfunction is self-reported, the history of erectile dysfunction is the prime indication for its use.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for facial feminization procedures (punch graft hair transplant > 15 punch grafts (15776); suction assisted lipectomy head and neck (15876); genioplasty 2/ sliding osteotomies (21122); repair, revision, and/or reconstruction of mandibular rami and/or body, sagittal split, without internal rigid fixation (21195); osteoplasty facial bones reduction (21209); malar augmentation prosthetic material (21270); rhinoplasty primary complete external parts (30410); repair brow ptosis (67900)). The World Professional Association for Transgender Health (WPATH) acknowledges that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH further states that in a patient with severe gender dysphoria, facial feminization procedures can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Moreover, facial feminization surgery can improve quality of life in transgender women. Based on the available documentation, the rationale for the requested surgery is to alleviate the patients clinically significant distress related to gender dysphoria. Specifically, the records establish that the purpose of the surgery is to directly treat the patients gender dysphoria. Further, the photographs show the patient has male features that can be addressed by the requested procedures. Thus, the requested facial feminization procedures (punch graft hair transplant > 15 punch grafts (15776); suction assisted lipectomy head and neck (15876); genioplasty 2/ sliding osteotomies (21122); repair, revision, and/or reconstruction of mandibular rami and/or body, sagittal split, without internal rigid fixation (21195); osteoplasty facial bones reduction (21209); malar augmentation prosthetic material (21270); rhinoplasty primary complete external parts (30410); repair brow ptosis (67900)) are medically necessary for this patient. Final Result: The reviewer determined that the requested surgery 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: Upheld

The patient is a one-year-old twin who was born 10 weeks premature followed by a two month NICU admission. The patients parents are requesting authorization for Synagis injections for the winter months. This request has been denied by the Health Plan. The patient does not meet the nationally accepted guidelines for consideration of Synagis. Specifically, the American Academy of Pediatrics recommends Synagis before the start of the RSV season for premature infants born at 29-32 weeks who are under six months of age. Although this patient was born premature, she is not under six months of age. In addition, the patient does not meet other qualifying criteria for consideration of Synagis. Therefore, Synagis is not recommended for this patient. Accordingly, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested coverage for residential treatment from a specific date and forward for treatment of the enrollees mood disorder, not otherwise specified, dysthmic disorder, oppositional defiant disorder, attention deficit/hyperactivity disorder, cannabis abuse, and parent-child relational problem.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient had no prior psychiatric hospitalizations.  After several weeks of treatment at the residential treatment center level of care, the provider described the patients mood as euthymic, without any psychosis or suicidal behaviors.  On the date in question, the provider described the patient as pleasant and cooperative.  He reportedly had limited insight, but was more engaged in therapy.  No aggressive or disruptive behaviors were described.  As of the date in question, the residential treatment was not and is not medically indicated.  He had no medical or psychiatric problems that required 24-hour level of care.  All told, residential treatment from the date in question and forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old male enrollee requested authorization and coverage of orthognathic surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees malocclusion.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested for Levitra 20mg for treatment of her erectile dysfunction. Findings:  The physician reviewer found that Levitra is one of the FDA approved PDE-5 inhibitors available in the United States, and it is an appropriate medication for the treatment of erectile dysfunction.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for interstitial brachytherapy treatments for treatment of the enrollees ductal carcinoma in situ (DCIS). Findings:  The physician reviewer found that APBI describes delivering adjuvant radiation to part of the breast after breast conserving surgery for early stage breast cancer. Delivery options include external beam intensity modulated radiation therapy (IMRT), brachytherapy catheters, electronic brachytherapy, intraoperative radiation therapy (IORT) and the MammoSite balloon. In general, the radioactive sources are delivered via multiple channels, each with multiple dwell positions. In this case, catheters would be placed, and afterloaded high dose rate sources would be used to deliver radiation. A recent study investigated APBI among 53 women with DCIS. The authors reported excellent survival and low breast tumor recurrence. In addition, others found pooled analysis reporting ipsilateral breast tumor recurrence rates of 2.6% at five years with no regional recurrences following treatment with APBI. Thus, the use of APBI for patients with DCIS, while not supported by level 1 evidence, is considered a viable treatment option in evidence based consensus statements from the American Society for Radiation Oncology (ASTRO) and American Brachytherapy Society (ABS). This patient is being considered for a clinical trial, which is a Phase II study. Given these findings, the requested interstitial brachytherapy treatments was medically necessary for treatment of this patients DCIS. 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 radiation oncology 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 56-year-old female enrollee requested spinal decompression at L4-5 with insertion of a Coflex device and spinal fusion at L5-S1 for treatment of her degenerative disc disease (DDD) and lumbar spinal stenosis.   Findings:  The physician reviewer found that the patient has no symptoms or signs of a lumbar radiculopathy with motor, reflex, sensory findings matching the L4-5 or the L5-S1 segment (Tarulli and Raynor). The provider described the patients leg symptoms as a radiculopathy but did not give an adequate detailed history of the symptoms. In addition, there is no documentation of a physical or a neurological exam. Further, her imaging studies show no evidence of instability greater than 4.5 mm motion at any level (Bambakidis, et al). Moreover, the patient has not had any interdisciplinary care for her chronic pain or a pre-operative psychiatric evaluation. She has no history of neurogenic claudication, cauda equine syndrome, and there is no evidence of fracture, infection, tumor, scoliosis or other criteria for fusion. The American Association of Orthopaedic Surgeons (AAOS) require a physical exam including assessment of strength, alignment and motion of spine as well as a neurologic exam to be considered for spinal fusion. However, these findings are not included in the records provided for review. The proposed surgery would not be performed in accordance with accepted standards of good medical practice. All told, the requested surgery is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested residential treatment center services for treatment of her alcohol and substance abuse.  Findings:  The physician reviewer found that this patient was not intoxicated and was not in acute withdrawal upon admission. The records indicate that her last use of any substance was three days prior to admission. In addition, she did not have psychiatric or medical comorbid condition. Although separated at the time, her husband of 20 years was supportive. She was motivated and she actively participated in the group process. Her quantity and substance use pattern did not require 24-hour supervision in a residential setting. She did not attest to suicidal ideation and was not a danger to others. Although the provider noted that there was an episode of emotional outbursts, this could have been managed at a lower level of care. In sum, the residential treatment center services were not medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested a CT scan of the abdomen for evaluation of her abdominal pain. Findings:  The physician reviewer found that CT scan of the abdomen performed on the date in question was not medically indicated for this patient. This patient presented with abdominal pain, chest and back tightness and dysphagia with solids.  These symptoms did not warrant evaluation with a CT scan of the abdomen.  This patients symptoms were suggestive of gastroesophageal reflux disease, esophagitis or a stricture.  The submitted documentation does not provide a differential diagnosis.  The medical records do not demonstrate the medical necessity of the diagnostic procedure at issue in this patients case.  The current medical evidence does not support this method of evaluation in this clinical scenario.  All told, the CT scan of the abdomen was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Xeljanz. The current medical evidence supports the requested medication in this clinical setting. This patient has failed treatment with high-dose infliximab despite adequate drug level and lack of anti-infliximab antibodies. Xeljanz (tofacitinib) has a different mechanism of action than aminosalicylates, immunomodulators, anti-tumor necrosis factor therapies, Entyvio, and Stelara. Xeljanz has been approved by the U.S. Food and Drug Administration for the treatment of ulcerative colitis. Sandborn and colleagues performed a double-blind, placebo-controlled trial of patients with moderate to severe ulcerative colitis. The authors noted, Patients with moderately to severely active ulcerative colitis treated with tofacitinib were more likely to have clinical response and remission than those receiving placebo. Studies have shown significant improvement in health-related quality of life and patient-reported outcomes with Xeljanz in patients with moderate to severe ulcerative colitis. American Gastroenterological Association (AGA) guidelines state, In adult outpatients with moderate to severe ulcerative colitis who have previously been exposed to infliximab, particularly those with primary nonresponse, the AGA suggests using ustekinumab or tofacitinib rather than vedolizumab or adalimumab for induction of remission. As this patient has already failed infliximab for ulcerative colitis, and has required ongoing corticosteroid therapy, there is sufficient support for Xeljanz in this setting. Therefore, Xeljanz is medically necessary for the treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested Crestor 20mg for treatment of his hyperlipidemia and peripheral vascular disease.  Findings:  The physician reviewer found that based on the records provided, the patient has hyperlipidemia that is not effectively controlled with simvastatin 40mg daily.  The recent data from Armitage and colleagues indicated a significantly higher incidence of myopathy (0.9%) in the group that received 80mg daily of simvastatin compared to the group that received only 20mg daily (0.02%).  This has led the Food and Drug Administration to issue a warning regarding prescribing the higher dose simvastatin to patients who have not previously taken the higher dose for at least 12 months without signs of myopathy.  However, there is no report of increased risk of myopathy using high dose (80mg) pravastatin or high dose (80mg) lovastatin.  Per the submitted documentation, there has not been a treatment failure or intolerance to either pravastatin 80mg or lovastatin 80mg, both of which may result in more potent low-density lipoprotein (LDL) reduction compared to the lower dose (40mg) simvastatin the patient has been prescribed.  All told, the requested Crestor 20mg is not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

A 25-year-old male enrollee has requested for emergency services for treatment of his toe pain. Findings:  The physician reviewer found that the patients primary care physician had sprayed the wart with nitrogen the day before. He reported that the area had become larger, darker and painful to touch. Swelling to the whole toe with redness and 6/10 pain was noted The patient reported lancing the lesion at home with bloody discharge and no pus. On physical exam, there was a 1cm hematoma on the great toe with no active discharge, some distal swelling and mild erythema. The patient was given the diagnosis of warts, status post removal and prescribed an antibiotic and a narcotic based pain medication.The evidence in the case shows that within 24 hours following treatment with liquid nitrogen, there were sufficiently severe symptoms (pain, swelling, necrotic-appearing lesions) such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize their health. A progressive infection could have been life/limb threatening without immediate intervention.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested laparoscopic Roux-en-Y gastric bypass surgery for the treatment of her obesity. Findings:  The physician reviewer found that with a BMI between 39 and 40 and early comorbidities, the patient meets the National Institutes of Healths criteria for consideration of weight loss surgery. It is highly likely that gastric bypass will ameliorate or eliminate her co-morbid conditions. Recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for real time remote heart monitoring.Findings: Two of the three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The use of different types of ambulatory electrocardiographic (ECG) monitoring for arrhythmias has evolved over the past 10-15 years. Guidelines from 1999-2000, the ACC/AHA guidelines for ambulatory electrocardiography, reflect that at that time, short duration monitors (24 or 48 hour) or symptom-activated external loop recorders (`event monitors`) were available. Newer systems with mobile outpatient telemetry for longer periods of time have developed more recently, and these newer systems are recommended for infrequent symptoms or when there is investigation of the cause of cryptogenic stroke and suspected atrial fibrillation. Research noted that a 2017 expert consensus statement, describe that the choice of monitor needs to be matched to the individual's symptom frequency. Use of mobile cardiac telemetry (MCT) is usually reserved for cases of infrequent symptoms or when the shorter duration monitors are negative or inconclusive. In this case, the patient was describing frequent symptoms, and there is no documentation that a shorter duration monitor had been used with results found to be negative or inconclusive. Accordingly, real time remote heart monitoring provided to the patient was not 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:All three reviewers are board certified in internal medicine, with subspecialty certification in cardiovascular disease, 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.