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

The patient has requested authorization and coverage for Stelara infusions every eight weeks. A large randomized controlled trial demonstrated the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al.). Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al.). A majority of these patients were able to discontinue steroids. The mechanism of Stelara is different that anti-TNF medications, which this patient has failed (Tuskey and Behm). Stelara is U.S. Food and Drug Administration (FDA) approved and recommended by guidelines for the treatment of Crohns disease (Lichtenstein, et al.). In this case, the patient has failed of Remicade in the setting of a high Remicade level without anti-Remicade antibodies. Per the American College of Gastroenterology guidelines, Individuals who have therapeutic drug levels and no antibodies with the presence of active mucosal ulceration are considered to have mechanistic failure and a medication with another class should be considered (Lichtenstein, et al.). The physician reviewer found that the American Gastroenterological Association guidelines state that in patients on an anti-TNF medication such as Remicade with therapeutic drug concentration and low or undetectable anti-drug antibodies, the recommended course of action is to switch to another drug class. For these reasons, Stelara infusions every eight weeks are medically necessary for 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

The patient is a 47-year-old female who underwent gastric bypass approximately two years ago. She has since lost 85 pounds. The patient indicates she has excess abdominal skin resulting in episodes of skin irritation and she is at risk for skin infections. Therefore, the patient has requested authorization and coverage for an abdominoplasty. The Health Plan indicates the submitted information does not demonstrate an abdominoplasty is medically necessary.The patient wishes to undergo an abdominoplasty to reduce the risk of skin irritation that could lead to infection. There is no evidence of infection or inflammation in the skin folds on the consultative examination. Further, the photographs submitted show excess skin, but not to the extent necessitating surgery. Conservative medical therapy is appropriate for management of this patients condition. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 26-year-old female enrollee has requested air ambulance transport services for treatment of her medical condition.  Findings:  The physician reviewer found that this patient was 27 weeks pregnant when she developed new onset seizures that were not easily controlled. The patient was unresponsive and in status epilepticus. The fetus was premature but viable. Patients who are actively seizing develop metabolic acidosis. Thus, both the mother and the fetus were in extreme physical jeopardy. The fact that the EEG was continuing to display epileptiform discharges demonstrates that there were two patients who were at risk in this situation. Ground transport  would have presented risk of harm to the patient and the fetus given the distance between hospitals.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested a computed tomography angiography (CTA) for evaluation of the enrollees chest pain. Findings:  Three physician reviewers found that there is no defined role for CTA in this patient population with a negative myocardial perfusion imaging study and atypical chest pain with neck factors. According to Metz, et al., the negative predictive value for myocardial ischemia and cardiac death in a patient with negative myocardial perfusion imaging was 98.8% over a 36-month period. While normal myocardial perfusion imaging does not exclude the presence of coronary atherosclerosis, it does signify a very low risk of short to mid-term adverse cardiac events. Although a CTA may allow the detection of atherosclerotic plaques that are not hemodynamically significant, the optimal management of such non-obstructive disease is not established, and thus, the clinical utility of CTA for this purpose is questionable.   Therefore, in this patients case, the use of CTA remains of unproven benefit and is not likely to result in an improved clinical outcome for this patient
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for compression gloves for treatment of the enrollees hand pain. Findings:  The physician reviewer found that the treatment and management of osteoarthritis includes non-pharmacologic, pharmacologic, and surgical options. Therapies are aimed at improving the pain and functional restriction that characterizes this disease. Splints are commonly used for patients that have pain at the base of the thumb. However, there is no indication for compression gloves for the treatment of osteoarthritis of the hands. In this case, the documentation supports the patient has a diagnosis of primary osteoarthritis of the hands, and she has been prescribed compression gloves for the treatment of her condition. The use of compression gloves or garments is indicated when there is a disruption of lymph or blood flow in a part of the body or swelling caused from lymphedema. Although the patient has a history of breast cancer with a mastectomy that would increase the risk for lymphedema of the upper extremity, there is no documentation to support that this is what the compression gloves are being requested for.  Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal 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 breast tomosynthesis for evaluation of her medical condition.   Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast tissue. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Based on the clinical documentation submitted for review, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three 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: All three reviewers are board certified in diagnostic radiology 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

The patient is a 55-year-old female who underwent gastric bypass in 2001. The patient has an overhanging pannus, which she reports is prone to infection. The patient has requested authorization and coverage for an abdominoplasty for treatment of her pannus. The submitted evidence does not demonstrate the patient has severe, visible skin irritation/ulceration resulting in a functional impairment. Excoriation and ulceration is not evident in the submitted photographs. Based upon the information provided, the patients abdomen shows findings consistent with deep and subcutaneous fat. In cases such at this, the requested procedure is cosmetic in nature and is not medically indicated. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested for venous ligation and division for treatment of his varicose veins. Findings:  The physician reviewer found that it does not appear the patient has undergone the appropriate work-up for consideration of vein stripping. This would typically include a consultation with a vascular specialist and a duplex ultrasound. The medical records provided do not support the need for vein stripping.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee, with a history of large B-cell lymphoma, has requested authorization for a PET scan.Findings:  Two physician reviewers found that the use of PET scans in the evaluation of large-cell lymphoma is endorsed by National Comprehensive Cancer Network (NCCN) guidelines and by the International Working Group (IWG). PET scans are recommended as baseline evaluations. If they are positive at baseline, they should be performed in follow-up. According to the IWG, PET is essential for post treatment follow-up of diffuse large B-cell lymphoma. PET scans are considered standard of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin condition. Findings:  The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. While this patient has some hanging skin, it is quite limited and does not constitute an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. The patients condition is normal in that the excess skin is not visibly affected by disease or infection and the amount of excess skin is not so great as to be considered abnormal. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California Health and Safety Code Section 1367.63. Furthermore, with regard to general concepts of medical necessity, there is no documented objective evidence of a functional impairment. The submitted photographs do not show any skin breakdown or rashes. An office visit note states there was no intertrigo. There is no description of office visits or physician treatment for skin rashes due to sagging skin. Therefore, the medical necessity of the proposed panniculectomy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services which include all of the specialists coming together as a group at the conclusion of the evaluations and/or diagnostic studies to formulate a diagnosis and treatment plan for treatment of osteoporosis and visual disturbance. Findings:  The physician reviewer found that in this case, the patient has multiple medical problems that are overall well-controlled.  He has access to multiple specialists, and his healthcare has been managed by his primary care physician with nursing and patient experience manager assistance. The documentation indicates there is good communication between the specialists and the primary care provider. The patient has been to multiple specialists, has had quick follow-up with his primary care provider after emergency department visit, and has had adequate advanced imaging with brain MRI/MRA.  His diabetes is well-controlled, his cholesterol panel is at goal and well-controlled, and his osteoporosis is stable.  He has a diagnosis of non-alcoholic fatty liver disease, which is common in patients with metabolic syndrome. His liver enzymes are normal, and he has had an appropriate diagnostic work-up for his liver condition. The patients main complaint is blurred vision. According to the submitted documentation, the patient has adequate care coordination in the current health system that he participates in. There is no documentation to suggest that a meeting where all the specialists discuss his care would change his current treatment or condition.  Additional specialist review with consultation at the Mayo Clinic for a second opinion and then services which include all of the specialists coming together as a group at the conclusion of the evaluations and/or diagnostic studies to formulate a diagnosis and treatment plan are not medically necessary for the treatment of this patient. 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 internal 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computerized axial tomography scan that was performed for evaluation of his hyperlipidemia.  Findings:  Three physician reviewers found that based on the records provided, this patient presented with no documented increased coronary risk, no documented symptoms concerning for coronary ischemia, and no ischemia on recent stress testing. In addition, the patients most recent lipid values while off lipid medication are not significantly elevated and his HDL is protectively high. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning and coronary calcium scoring. Treatment change or addition based on the results of screening with coronary CT scanning/calcium scoring has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Given these findings, the computerized axial tomography scan that was performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Three reviewers determined that the service at issue was 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. Final Result: Three reviewers determined that the service at issue was 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 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: Urgent Care
Decision: Upheld

The parent of a 13-year-old female enrollee has requested emergency services for the 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 parents circumstances would believe their child 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 reported a one day history of swollen tonsils. The patients mother stated that she became alarmed by the appearance of a lump on the patients right tonsil. The patient was not experiencing any pain, fever, or difficulty breathing or swallowing. The appearance of a spot on a patients tonsil may be cause for concern, but the issue is whether these symptoms were sudden or severe enough to cause a prudent layperson to reasonably expect that the absence of receiving immediate medical attention could result in serious risk of harm. The patient had normal vital signs and had no evidence of airway compromise. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old male enrollee has requested for Celebrex for treatment of his pain secondary to diabetic neuropathy. Findings:  The physician reviewer found that the patient has tried multiple medications for his neuropathy without benefit.  He has not been able to tolerate an NSAID (with PPI) because of a gastrointestinal disturbance.  He has been able to tolerate Celebrex in the past (with noted benefit); therefore it is a reasonable choice as a therapeutic agent.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested a MRI of the breast for evaluation of her segmental mastectomy.  Findings:  Three physician reviewers found that this patient has a history of invasive ductal cancer of the left breast which is triple negative. There is a known propensity for this type of tumor to be multifocal in the involved breast and sometimes occurs in the contralateral breast.  The providers caring for this patient have observed several foci of abnormal enhancement in the treated left breast outside of the surgical resection site on an outside MRI. Mammographic and sonographic evaluation of these areas has been negative. Since the abnormalities were only visible on MRI it is reasonable to image the breast to evaluate for any progression using the only modality on which they have been evident. Also, an additional benefit of the MRI was the evaluation of the probably benign lesion which had been noted in the right breast. MRI is the procedure of choice for this patient and is not considered investigational in this clinical scenario. In sum, the MRI in question was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-month-old female enrollee has requested Synagis to assist in the prevention of respiratory syncytial virus (RSV) infection. Findings:  The physician reviewer found that while the patient was born prematurely, and as such has experienced some of the complications of premature birth, her respiratory disease does not meet the accepted definition of chronic lung disease (CLD) of prematurity as she only received supplemental oxygen for 10 days in the NICU. The patient does not automatically qualify for a second year of Synagis therapy according to the AAP guidelines.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee requested authorization and coverage of the medication vicoprofen for the treatment of chronic back pain.  The health plan denied the enrollees request indicating that the requested medication 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 12 rental units of high frequency chest wall oscillation (HFCWO) system, E0483 for treatment of the enrollees chronic obstructive pulmonary disease. Findings:  The physician reviewer found that The documentation provided does not support the medical necessity for the requested equipment in this clinical setting. The medical literature suggests the following criteria as indications for the use of HFCWO: documented need for airway clearance, a diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disorder with inability to clear secretions, or inability to use other airway clearance devices such as inspiratory valves, manual chest percussion, or postural therapy. The records provided do not indicate that this patient meets the criteria as noted in the medical literature. While this patient may have severe COPD with frequent exacerbations requiring hospitalization, the etiology of these exacerbations are unclear, with some reports related to airway clearance and in other instances related to noncompliance. There is no documentation provided that indicates the patient has bronchiectasis, evidence of recurrent infections or current use of airway clearance devices. Moreover, there is minimal evidence in the literature that indicate the use of HFCWO benefit patients with COPD exacerbations. Therefore, 12 rental units of HFCWO system-E0483 is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

A 31-year-old female enrollee requested reimbursement for inpatient skilled nursing facility services the enrollee received from 12/20/02 to 1/1/03. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the services at issue were medically necessary.