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

A male enrollee requested Provent nasal expiratory positive airway pressure (EPAP) for treatment of his obstructive sleep apnea (OSA).  Findings:  Two physician reviewers found that this patient has mild positional OSA. However, he only has mild changes when sleeping supine. This is positional sleep apnea and the standard of care is a vest with a tennis ball in it, which is worn so the ball prevents supine sleep. All told, the requested Provent device is not likely to be more beneficial for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 40-year-old female with working diagnoses of rheumatoid arthritis, severe headaches, and complaints of temporomandibular joint (TMJ) pain and crepitus. Based upon the information submitted, no history and physical examination and no imaging has been performed with respect to the patients TMJ complaints. Furthermore, no evaluation has been performed to determine whether there is a possible link between the patients TMJ complaints and her headaches. Moreover, there appears to be no treatment plan in place for this patient. The patient is seeking a consultation with an oral surgeon for evaluation of her condition. The Health Plan has denied this request.Given the patients complaints, a complete evaluation is necessary to obtain a proper diagnosis and development of an appropriate treatment plan. Such an evaluation would involve evaluation of the patients temporomandibular joints, her muscles of mastication, and her dental occlusion. Therefore, a referral to an oral surgeon is medically appropriate and indicated. As such, I have determined the requested consultation is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick for treatment of the enrollee who has a history of coronary artery disease and hyperlipidemia. Findings: The physician reviewer found that the documentation provided supports the medically necessity for the requested medication in this clinical setting. Based on the records, this patient has increased coronary risk, marked hyperlipidemia with documented statin intolerance and up to moderate coronary stenosis on prior coronary CT angiogram. In this circumstance, the patients increased risk and coronary CT angiogram results provide enough evidence, to recommend aggressive lipid reduction with high intensity medication according to standard secondary prevention guidelines. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Based on the CT angiogram results, the patient fits the latter criteria. In this setting, Repatha has been shown to both reduce cholesterol and decrease adverse cardiac outcomes in randomized prospective trials  Zetia may also be considered given favorable outcomes data with this medication but would not be expected to reduce the patients LDL cholesterol to a recommended goal of less than 70 mg/dl according to secondary prevention guidelines. As such, Repatha Sureclick 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old male enrollee has requested for Genotropin growth hormone for treatment of his growth hormone deficiency.   Findings:  The physician reviewer found that the most current guidelines from the American Association of Clinical Endocrinologists (AACE) indicate that the diagnosis of growth hormone (GH) deficiency can be made in a patient with organic disease (Cook, et al). With regard to treatment, the requested GH therapy will positively affect the patients health, including his lipid profile, cardiovascular status, diabetes, bone density, and life expectancy (Burger, et al). Moreover, once treated with Genotropin GH therapy, the patient exhibited substantial improvement with increased mental function and physical energy. Therefore, the requested Genotropin GH therapy is medically necessary for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Computed tomography (CT) of the chest and CT of the abdomen and pelvis. This patient presented with undifferentiated pleomorphic sarcoma of the left buttock. The patient underwent evaluation with CT of the chest and CT of the abdomen and pelvis. Basile and colleagues noted that, patients diagnosed with isolated lymph node metastases have a prognosis similar to that of patients diagnosed with localized American Joint Committee on Cancer stage III soft-tissue sarcomas, which also equates to a significantly better overall survival compared with patients with systemic metastases. The authors recommended modifications to the American Joint Committee on Cancer staging system to distinguish patients with isolated lymph node metastases to acknowledge their better prognosis compared with those with systemic metastases. For assessment of a patients condition for staging and treatment purposes, the National Comprehensive Cancer Network (NCCN) guidelines recommend a chest CT for initial staging for all patients with sarcoma for initial staging (von Mehren, et al.). Given the location of this patients soft tissue sarcoma, a CT of the abdomen and pelvis was also appropriate. The findings on these CT studies enables staging and treatment recommendations. For these reasons, the CT of the chest and CT of the abdomen and pelvis were medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee requested speech therapy and ongoing occupational therapy (OT) for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that a portion of the requested services are medically necessary for treatment of the patients medical condition.  According to a speech-language evaluation, the patients communication goals are being addressed in his comprehensive ABA program. Given that his speech therapy is being addressed through ABA, additional speech therapy is not medically necessary.  Occupational therapy has been requested to address the patients coping strategies when overwhelmed. The record demonstrates that the patient has fears that lead to his avoidance of elevators/escalators and long car rides. Sensory processing abnormalities, anxiety and restricted and repetitive behavior frequently co-occur in autism spectrum disorders. According to Barton and colleagues, Sensory-based therapies are designed to address sensory processing difficulties by helping to organize and control the regulation of environmental sensory inputs. As such, using an OT sensory processing technique to address the patients anxieties is clinically appropriate and medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested for Botox injections for treatment of her chronic headaches with migraines.   Findings:  Two physician reviewers found that recent evidence has shown that botulinum toxin also blocks the neuronal release of nociceptive mediators such as substance P, glutamate, and calcitonin gene-related protein. In a recent study, Frietag et al. suggested that botulinum toxin may be an effective treatment in chronic migraine without medication overuse. Mathew, et al. and Silberstein, et al. also suggested the efficacy of Botox as a prophylactic treatment for chronic daily headaches. Mathew, et al. (2008)  also opined that chronic migraine patients respond better to Botox than chronic tension-type headaches.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee requested acute inpatient psychiatric services  for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that the patient was plagued with a debilitating unilateral affective disorder and a co-occurring chronic anxiety disorder. The patient had an exacerbation of her mental illness that compromised her baseline functionality. Although future oriented and not acutely suicidal, her thoughts of death and largely neurovegetative symptom complex that generated prompt consideration of electroconvulsive therapy as a primary therapy warranted hospitalization initially.  However, the record does not support treatment at the acute inpatient level of care shortly thereafter.  The nursing staff completed a suicide risk assessment during intake and the patient denied suicidal ideation. She had no psychosis, chemical dependency or insomnia. She endorsed multiple protective factors including a child in the home, supportive peer network, good connection with her therapist and doctor, and the ability to consider alternatives to suicide, utilize positive coping skills and seek help if needed. The following day, the patient slept well. She participated in only one group. She denied suicidal ideation. She had no plan to end her life and she was medication adherent with no side effects. The patient was motivated for the partial hospital program and had a close, supportive friend in the community.  Although symptomatic and in need of specialty care, the medical record indicated that the patient was not suffering from an acute psychiatric syndrome.  As such,  I have determined that a portion of the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested a colonoscopy for an evaluation of his risk of colorectal cancer. Findings:  The physician reviewer found that the American Gastroenterological Association (AGA) clinical guidelines and rationale for colorectal cancer screening, patients with only 1 or 2 small (measuring less than 1 cm) tubular adenomas with only low-grade dysplasia should have a repeat colonoscopy every 5 -10 years. These criteria are reiterated by the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG). This patient had one polyp measuring less than 1 cm identified as adenomatous, which was non-dysplastic. This patient does however have a family history of colorectal cancer. Therefore, the clinically appropriate management would be to perform a follow-up colonoscopy five years after the initial screening with polyp removal.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical treatment of rib fractures (CPT 21813) for treatment of the enrollees rib fractures. Findings:  The physician reviewers found that The surgical treatment of rib fractures (CPT 21813) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Surgical fixation of rib fractures sustained from flail chest injuries decrease intensive care unit (ICU) time, mortality, pulmonary complications, and hospital length of stay and result in improved health care-related outcomes. Multiple studies have shown that patients with flail chest have substantial benefit such as decreased ventilator, improved pulmonary function, and improved long-term functional outcome when they undergo surgery compared with non-operative management. Open reduction and internal fixation of the clavicle for stabilization of this patients unstable fracture was indicated and medically appropriate in this case. Plate fixation has been shown to be superior to intramedullary fixation for these clavicle fractures. Furthermore, the surgical treatment provided was better than any other standard treatment for management of the flail chest and unstable clavicle fracture in this clinical setting. Final Result: All three reviewers determined that the services at issue were 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: Physician reviewers number one, two, and three are board certified in orthopedic surgery and 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 58-year-old female enrollee has requested authorization and coverage for a CT scan of the pelvis for evaluation of her pelvic pain. Findings:  The physician reviewer found that  the Health Plans guideline requiring a pelvic ultrasound for evaluation of pelvic pain prior to CT scan unless extenuating circumstances are present is a reasonable approach. In fact, the American College of Radiology rates ultrasound as slightly more appropriate than CT scan for evaluating pelvic pain, except in obese patients. The American Academy of Obstetrics and Gynecology recommends the use of ultrasound in the evaluation of pelvic pain and endorses CT only when ultrasound findings are abnormal.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. This patient presented with severe incapacitating low back pain radiating into the right lower extremity to the calf. Clinical examination demonstrated significant motor defects consistent with imaging evidence of a large recurrent L4/5 disc bulge with extrusion resulting in severe spinal stenosis and L4 and L5 nerve root compression. Reasonable conservative treatment was attempted, including oral steroids, anti-inflammatory medications, and activity modification. He was recommended for L4/5 revision microdiscectomy and decompression and underwent surgery. Given the severity of pain and progressive neurologic deficits, the surgical intervention would be considered emergency medical services as defined in Health and Safety Code section 1317.1, subdivision (a)(1). The services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. 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

The patient is a 15-year-old male with a diagnosis of cerebral palsy with spastic quadriplegia. He underwent a dorsal rhizotomy in 1997. He has also been receiving Botox injections to the lower extremities. He has been receiving physical therapy once a week because of a regression in ambulation skills. Most recently he has been using a Lite Gait and Gait Keeper as equipment to improve his skills. The patients provider has documented the gains the patient has achieved while utilizing this equipment. The Health Plan has denied coverage for the Lite Gait and Gait Keeper.A review of the literature regarding locomotor therapy and assisted training demonstrates there is evidence supporting such therapy for patients with cerebral palsy. There is also significant support for utilizing such therapy in the stroke population. Furthermore, the patients records demonstrate the equipment is designed for repeated use, is being used to treat and to improve functioning and to prevent further deterioration of the patients medical condition. Moreover, there is evidence that the equipment has benefited the patients condition. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested lymph node transplant (lymphatic microsurgery) for treatment of her lymphedema secondary to breast cancer treatment.  Findings:  The physician reviewer found that in the medical literature, the proposed surgical treatment is not the standard of care in routine cases of lymphedema and should only be considered once failure of non-operative therapy has been firmly established. The above references document some promise in microsurgical treatment of lymphedema and Chang concluded that, Lymphaticovenular bypass may effectively reduce the severity of lymphedema in breast cancer patients. This patient was referred to a plastic surgeon who found the patient to be a good candidate for lymphedema free flap surgery to relieve some of her symptoms. In addition, the provider reports that the patient has functional pain and decreased hand function that has failed conservative management. For these reasons, the requested surgery should be considered medically necessary and approved for this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for food specific immunoglobulin G (IgG) allergy panel (CPT 86001 x 11). This patient underwent IgG level testing to help assess food allergy response and to direct treatment. However, the use of food specific IgG level testing has not been demonstrated to predict true food hypersensitivity and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. In addition, IgG4 is generally increased in patients who have successfully undergone oral immunotherapy for milk or peanut allergy. Thus, food specific IgG should not be used as a tool to diagnose food allergy and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. IgE Immunoassays have demonstrated high positive predictive accuracy in children for several of the major food allergens. In conclusion, the food specific IgG allergy panel (CPT 86001 x 11) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three of the three physician reviewers found the food specific IgG allergy panel (CPT 86001 x 11) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in allergy and immunology, and rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology 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: Overturned

The enrollee is requesting authorization and coverage for removal of mammary implant material and the delayed insertion of breast prosthesis. The enrollee has a history of breast cancer and underwent bilateral mastectomy and breast reconstruction. She was evaluated for complaints of deformity related to wrinkling of the skin and an unaesthetic pectoralis animation deformity. Examination showed a slight deformity to the right breast and a discrepancy of the inframammary fold. There was age-related epidermal thinning and asymmetry in the right axillary region. The physician discussed revision surgery, including liposuction to the right axilla, a change in incision site, and a recommendation to downsize her implants. This enrollee underwent bilateral mastectomies with breast implant reconstruction. Her implants are too large and have wrinkling and pectoralis animation deformities.  Review of the record substantiates the revision of the reconstruction with implant exchange is medically necessary. The enrollee has continued abnormality of her breasts following breast cancer reconstruction. The abnormalities are due to breast cancer disease, and correction of the deformities is a stage of her reconstruction. The alleged abnormality constitutes an abnormal structure of the body that is due to disease. The requested surgery will help to create a normal appearance. The plastic surgery literature has several studies which show the outcome of breast reconstruction can change over time, due to age, and weight gain and loss.  The quality of the reconstruction can change and implants can rupture. Breast reconstruction is not a one-time procedure. Revisions are commonly required and can reasonably be considered a stage in breast reconstruction; which is now understood to be a multi-stage process, including revisions.  Implant exchange is a stage of her reconstruction to restore her breasts to her pre-mastectomy appearance and will provide more than a minimal improvement in the appearance of the enrollee.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 plastic 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 similar medical condition.