Persius/imr-appeals huggingface dataset:
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 this patient was evaluated in the emergency department due to a right earache for the past seven hours. She was discharged with a diagnosis of otitis media and a given a prescription for oral Amoxicillin and ear drops. 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. The patients parent states that she was concerned that a delay in care could cause impairment of her daughters hearing. Upon presentation to the emergency department, the patient was described as being in mild distress. Her pain level was documented as a 6 on a 1 to 10 scale, which though significant, does not indicate severe pain. There was no evidence of discharge from the ear, hearing loss, sore throat, headache, nausea or chest pain. Vital signs were stable. Given the patients presentation, although her symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe the patient was at risk of serious jeopardy to her health, serious impairment to bodily function or serious dysfunction of a bodily organ or part without emergency medical care. As such, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested Sovaldi with Olysio for treatment of her chronic hepatitis C genotype 1b.  Findings:  The physician reviewer found that the current standard of care for hepatitis C genotype 1a and 1b treatment includes two directly acting antiviral drugs which typically include a protease inhibitor and polymerase inhibitor directed against non-structural proteins involved in hepatitis C replication. The sustained virologic response rate is greater than 90% in patients with and without cirrhosis. This patient has a diagnosis of cirrhosis which is supported by evidence of portal hypertension on laboratory testing and the results of the hepascore. A liver biopsy is not needed to support an indication for the requested Sovaldi and Olysio combination therapy. Moreover, the patient has already failed interferon based therapy. For these reasons, the requested medications are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronan) injection in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has received excellent benefit from viscosupplementation with Synvisc-One in the past. Furthermore, the options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Therefore, the requested Synvisc-One (hyaluronan) injection in both knees is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned

A 69-year-old male enrollee has requested for deep brain stimulation for treatment of his Parkinsons disease. Findings:  Two physician reviewers found that deep brain stimulation has widespread acceptance as being effective in treating severe Parkinsonian tremor, essential tremor and late motor manifestations of Parkinsons disease.  Parkinsons tremor is notoriously unresponsive to medical therapy. This patient has exhausted all reasonable medical options other than deep brain stimulation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to expression of suicidal ideation prior to RTC admission. The records document that the patients friend brought the patient to the hospital given concern about the patient harming herself. The patient also experienced a recent alcohol relapse with loss of self-control and harmful behaviors with no demonstrated ability to abstain from use. There is support of clear compromise of ability to care adequately for oneself. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her recent struggles with alcohol relapse and fulfilling job responsibilities. The patient was also noted to have a conflictual relationship with her father. The patient has only been able to maintain gains while participating in treatment in a structured setting. The records document recent gains and stabilization in function achieved while participating in treatment in a structured and protected setting. For dimension 3, the patient has significant comorbidities (score 3) considering her recent substance use with detrimental effects on presenting symptoms, worsening depression and anxiety and inciting suicidal ideation. Recent substance use has had clearly detrimental effects on the presenting disorder but has been temporarily arrested through use of a highly structured or protected setting. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to ongoing conflicts with her father and her ex-husband. The records document significant discord and difficulties in family relationships and alienation from social interaction. For dimension 4B, the patients recovery environment is minimally supportive (score 4) since the patient has limited social support and has ongoing problems with her ex-husband. The patients father is housing and employing the patient, but he is frustrated with the patient. The patient is on bad terms with an unwilling to use supports available in a constructive manner.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 29-month-old female enrollee has requested  for occupational therapy, physical therapy and speech therapy for treatment of the enrollees global developmental delay.  Findings:  The physician reviewer found that it is the medical community standard to offer such children appropriate rehabilitative services. Even small verbal and motor gains can allow the patient significant improvement in controlling and adapting to her environment. It is a medical necessity that this patient receive speech, occupational, and physical therapy.  There is a significant and robust medical literature supporting the positive effect of these therapies in a child with delays similar to this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan Orthovisc injections  of the left knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent response to viscosupplementation in the past with documented pain relief and the ability to continue working. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Under these circumstances, hyaluronan Orthovisc injections of the left knee are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female who has requested labial reduction and removal of excess perianal tissue. Based upon the information provided, it appears the patient first raised the issue with her primary care physician in September 2003 when she complained of labial tissue rubbing against her thighs during physical activity. On exam, the primary care physician noted hypertrophy of the labia minora and referred the patient to a gynecologist. The gynecologist noted the labia minora were large but without erythema or induration and referred to the patient as having a variation of labia minora. The gynecologist also apparently discussed the risks of labial reduction with the patient to include scarring, nerve damage, and lymphedema. At the patients request she was referred to another gynecologist for a second opinion; a nurse practitioners note did not indicate any labial abnormality but did question the presence of a hemorrhoid or skin tag in the perianal area. The patient was then referred to a plastic surgeon for consideration of a labial reduction and removal of excess perianal tissue. The Health Plan has denied authorization and coverage for the requested procedure indicating it is not medically necessary. The submitted clinical information reveals no medical indication for a labial reduction and removal of excess perianal tissue. The patients providers notes indicate there was no evidence of erythema or induration. In addition, there is no evidence that conservative therapies have failed to help the patients condition. Furthermore, the requested procedure could cause pain and disfigurement. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for stress echocardiogram for evaluation, who presented to her provider for annual examination. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue. Based on the records provided,the patient has been diagnosed with an isolated right bundle branch block. However, there were no documented symptoms concerning for any acute cardiac condition, no documented cardiovascular physical examination abnormalities and no documented chest radiographic abnormalities. In this circumstance, the medical records provided to not support the need for obtaining a stress echocardiogram. An isolated right bundle branch block without any other documented abnormalities is generally benign and is not an accepted indication for stress testing.  Current guidelines, endorsed by several national organizations, also do not consider stress echocardiography appropriate in this clinical setting. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest wearable cardioverter defibrillator. Current data from multiple trials have advocated the use of a LifeVest wearable cardioverter defibrillator after an initial diagnosis of severe left ventricle (LV) dysfunction with an ejection fraction (EF) of 35% or less, along with guideline directed optimal medical therapy. This patients EF was 19%. The recommended timing of placement of a LifeVest based on current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines is within 40 days of an acute myocardial infarction, or within 90 days of guideline directed medical therapy for an initial diagnosis of congestive heart failure with a severely reduced EF. There was a reasonable expectation that the patients EF would improve after revascularization given the myocardial viability study performed preoperatively, which would have avoided the need for permanent ICD placement. For these reasons, the Zoll LifeVest wearable cardioverter defibrillator was 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 Zoll LifeVest wearable cardioverter defibrillator was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient was noted to have atrophic gastritis with intestinal metaplasia but no dysplasia, and a history of adenomatous colon polyps. She was being treated with pantoprazole. The patient underwent an esophagogastroduodenoscopy (EGD) for atrophic gastritis. This revealed an irregular Z-line, mild atrophic gastritis in the gastric body and fundus, and a normal duodenum. Biopsies showed intestinal metaplasia in the antrum but not the fundus. Per the grievance and appeals review form, the patient was concerned about her risk for cancer due to her brothers history of esophageal cancer. The patient has requested reimbursement for the esophagogastroduodenoscopy (EGD) procedure (CPT 43239). The Health Plan denied the request and reported that the service at issue was not medically necessary for the evaluation of this patient. At issue in this case is whether the esophagogastroduodenoscopy (EGD) procedure (CPT 43239) that was performed was medically necessary for the evaluation of this patient. The ASGE Standards of Practice Committee reported, Patients with gastric intestinal metaplasia (GIM) may have a greater than 10-fold increased risk of gastric cancer than the general population. Authors reported, Increased risk for incident gastric cancer among patients with GIM.  The authors noted, Patients and providers may reasonably elect to undergo short-interval upper endoscopy to characterize presence/absence of these features or commit to longitudinal surveillance if these features are known to be present. Similarly, because we found evidence supporting increased risk for gastric cancer among patients with GIM and a first-degree relative with gastric cancer, patients with GIM and a family history could reasonably elect for longitudinal endoscopic surveillance. In this case, the patient was noted to have atrophic gastritis with intestinal metaplasia, and she reported concern for gastric cancer due to her family history. The medical evidence supports the service at issue in this clinical setting. Therefore, the esophagogastroduodenoscopy (EGD) procedure (CPT 43239) that was performed was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service was 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mandibular adjustment device. The Health Plan has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees obstructive sleep apnea (OSA).The documentation provided does not support the medical necessity of the device at issue in this clinical setting. In this case, the patient was prescribed an oral appliance. It cannot be determined from the medical records provided, if the patients first sleep study was diagnostic for OSA as the total AHI was not provided. Additionally, current practice state that although oral appliances (OAs) have been shown to improve physiologic sleep parameters, CPAP (continuous positive airway pressure) appears, in our meta-analyses, to be superior to OAs in reducing the AHI, arousal index, and oxygen desaturation index and improving oxygen saturation, and therefore should still generally be the first-line option for treating OSA. Likewise, guidelines from the American College of Physicians also recommend the use of CPAP as a first-line therapy for OSA. Based on the documentation provided for review, the mandibular adjustment device was not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the device at issue was 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 neurology with sub-specialty certification in sleep 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Xeljanz. The records provided for review document that this patient has symptoms consistent with alopecia totalis. The provider charted that the patient has failed to substantially respond to treatment with methotrexate, minoxidil, and clobetasol cream. The patients provider has recommended treatment with Xeljanz, which is a Janus kinase (JAK) inhibitor. Overall, there is adequate evidence that JAK inhibitors, in particular Xeljanz, is efficacious for the treatment of patients with alopecia totalis. Liu and colleagues concluded that Xeljanz should be considered for the treatment of severe AA [alopecia areata], alopecia totalis, and alopecia universalis. King and colleagues noted that baricitinib, another JAK inhibitor, has demonstrated efficacy in the treatment of patients with alopecia areata. Similarly, there are adequate large case series reports in the medical literature reporting the improvement of symptomatic alopecia with Xeljanz (Ibrahim, et al.). This patients records document failure to respond to other systemic medications including methotrexate, and topical treatments including steroids and minoxidil. Therefore, the requested Xeljanz is 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.