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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees bilateral knee osteoarthritis. Findings: The physician reviewer found that the benefit of viscosupplementation for more than two series has not been established in the scientific literature. In addition, multiple repeat series of viscosupplementation is not U.S. Food and Drug Administration (FDA) approved and is not supported by the Centers for Medicare and Medicaid Services (CMS). 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Flector patch for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Oral nonsteroidal anti-inflammatory medications are contraindicated in patients who have a side effect of gastrointestinal irritation due to increased risk of gastric ulcers and gastric perforation.  In this patients case, there is no documentation of gastrointestinal irritation with oral nonsteroidal anti-inflammatory medications.  Based upon the medical records, there are other appropriate alternative oral medications that may be beneficial for this patients chronic pain.  In acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical nonsteroidal anti-inflammatory medications.  Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical nonsteroidal anti-inflammatory medications with placebo. They found that topical nonsteroidal anti-inflammatory medications were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Flector patch is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-specialty certification in pain 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 Cartiva joint arthroplasty, a synthetic cartilage implant, used during surgery. This patient presented to her provider with complaints of ongoing great toe pain. Per the providers notes, imaging revealed narrowing of the dorsal cartilage interval of the first metatarsophalangeal joint with associated osteophytes. The patient also developed secondary hallux valgus interphalangeus with the left big toe impinging on the second toe. The patient underwent placement of the Cartiva implant for treatment of great toe pain. The Cartiva implant utilized in this patients surgery is not supported by adequate data in the peer-reviewed medical literature when compared to cheilectomy or arthrodesis. A prospective randomized multicenter trial reported by Baumhauer and colleagues compared the Cartiva implant to arthrodesis found that the Cartiva implant outcomes were not inferior to arthrodesis. However, the Cartiva interposition hemiarthroplasty implant continues to be evaluated to determine whether the procedure is safe and effective in the long-term as an alternative to cheilectomy and arthrodesis. Therefore, the Cartiva joint arthroplasty, a synthetic cartilage implant, used during surgery was not 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 Cartiva joint arthroplasty, a synthetic cartilage implant, used during surgery was not 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 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided.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 services at issue were not necessary for treatment of an emergency medical condition. No emergent condition was identified and no emergent treatment was provided. In this case, the patient presented to urgent care on during the dates in dispute with reports of abdominal pain for three months. He had previously undergone extensive testing and his symptoms were improving while taking an H2 blocker. This patients symptoms had not suddenly worsened. No associated symptoms were present such as fever, vomiting, or abnormal vital signs, to suggest an acute abdominal emergency. The services provided to this patient on do not meet criteria for emergency medical services.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

The parent of a four-year-old male enrollee has requested speech therapy and occupational therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient was recognized as having significant language delay.  Tests also reported expressive and receptive language between 31-40% below age expectations. The patient had group speech therapy initiated in an early intervention program at that time. Initially the patients speech therapy was limited to group pull-out sessions until more recently. When tested again, he was noted to be even further delayed with receptive and expressive language at the 1-2% level. Despite these limited efforts at speech therapy, his delay has increased. A paper by Myers and colleagues indicates, Treatment by a speech pathologist [for autistic children] is usually appropriate and that, traditional, low intensity pull-out [speech therapy] service delivery models are often ineffective. The article by Landa discusses the need for intensive individual speech therapy in autistic children and stresses the need for early intervention. Yoder and McDuffie note that speech therapy should be combined with other intensive therapies to have maximal effect. Speech therapy is medically necessary for this patient. Early limited group sessions have resulted in a decline in his speech abilities. As indicated above, the medical literature supports individual speech therapy as an appropriate and indicated intervention for autistic patients such as this patient. Concerning the requested occupational therapy, many children with autism have gross or fine motor delays and experience some level of motor dysfunction. Occupational therapy is considered a medically necessary intervention in this setting. Case-Smith and Arbesmans study is an evidence-based review of the need for occupational therapy in autistic children. Schaaf and colleagues discuss the utilization of sensory integrative approaches to improve motor and sensory skills in autistic children. This patient has demonstrated poor fine motor skills and it is therefore medically necessary for him to receive individual occupational therapy to assist with his functional deficits.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Genotropin for treatment of the enrollees Prader-Willi syndrome. Findings:  The physician reviewer found that the request for Genotropin is not medically necessary for treatment of the patients medical condition. GH treatment for children with Prader-Willi syndrome has been shown to improve linear growth and promote growth of lean body mass, decreases fat mass by increasing fat oxidation and total body energy expenditure, and improves cardiovascular risk factors. Complications of GH therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, GH therapy is considered to be generally safe in this population. Long-term GH treatment is known to improve body composition, muscle size and quality and increases muscle strength and exercise independently from the GH secretory status. Although GH therapy is clinically indicated for children with Prader-Willi syndrome, there is no specific brand name that has been shown to be more efficacious or that result in a lower rate of adverse effects. Given that the Health Plan has Nutropin AQ Nuspin pen injector, the request for Genotropin has not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 pediatrics with sub-specialty certification in pediatric endocrinology 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

A 53-year-old male enrollee requested  gene testing for prostate cancer for medical evaluation of his medical condition.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. The use of genetic screening to detect the presence of prostate cancer is not the standard of care in clinical practice. Digital rectal exam along with periodic determination of PSA levels and velocity as well as repeat biopsies are the commonly employed modalities to determine clinical status. As such, the testing at issue was not likely to be more beneficial for evaluation than standard diagnostic studies in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a four-year-old male who was diagnosed with autism in late 2005 at the age of three years and seven months. He began speech therapy in December 2005 following an evaluation where deficits in the areas of expressive, receptive, functional and pragmatic language were identified. His re-evaluation in March 2006 showed progress and he had a good prognosis for continued functional improvement according to the therapists assessment. The patient is also followed by a developmental psychologist who recommends continued speech therapy sessions, twice per week to address expressive language delays. The parents request for reimbursement for the speech therapy already provided and prospective authorization of speech therapy was denied by the Health Plan based upon a determination that the therapy was/is not medically necessary.Autism is a serious neuropsychiatric disorder of unknown cause with a potentially devastating impact on childhood development. Without age appropriate language skills, children with autism are disadvantaged in educational and social venues. According to the records provided for review, this patient has made positive strides with twice a week speech therapy. Although the etiology of autism is not clear, it is nonetheless a serious condition with significant impact. The March 2006 Update Report recommended an additional four months of therapy, at which time the patients goal achievement and need for further therapy should be re-evaluated. As such, I have determined the speech therapy provided from November 2005 through July 2006 was medically necessary for treatment of the patients medical condition. Authorization of continued speech therapy should be based upon the next re-evaluation in the July 2006 timeframe. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services and substance use treatment. Due to the lengthy history of substance use and lack of a sober support network, a residentially-based preliminary introduction to chemical dependency treatment was medically appropriate. However, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of 1/27/18. This patient embraced recovery principles and was both active in treatment and motivated in his quest for sobriety. He was not experiencing withdrawal or significant medical or psychiatric symptoms. He was stable on psychotropic medications that were not being adjusted.  He was future oriented, and he had access to safe housing. Although the parent-child dynamic was strained, he had a supportive family. The records on 1/26/18 indicated that the patients mother was available to live with him. This was significant for both supportive and therapeutic purposes, particularly since the patient had prior success with sobriety when residing with his parents. Further, the patient had no prior history of chemical dependency treatment, such as anti-craving medication, 12-step facilitation, contingency management or cognitive behavioral therapy, in the community, outpatient, intensive outpatient or partial hospital settings.  This is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time.  Thus, residential treatment center services and substance use treatment provided from 1/23/18 through 1/26/18 were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 parent of a six-year-old male enrollee has requested speech therapy services; and that the speech therapist be experienced in treating children with apraxia and autism and/or trained in Dynamic Temporal and Tactile Cueing (DTTC) and/or trained in Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT); and that speech therapy services be delivered in-home for treatment of the enrollees autism, childhood apraxia of speech and global developmental delay. Findings:  The physician reviewer found that there is limited scientific evidence which supports the effectiveness of the PROMPT technique. According to the study by Dodd and Bradford, three children were treated with three different speech therapies using a self cross over control, and the PROMPT method was the least effective of the three. Furthermore, there is a lack of significant evidence supporting the use of DTTC in this setting. In this patients case, he underwent an extended course of therapy utilizing both the PROMPT and DTTC techniques with only limited improvement. Moreover, a licensed speech therapist would be expected to have sufficient expertise to treat children with apraxia and autism. In sum, the request that the speech therapist be experienced in treating children with apraxia and autism and/or trained in DTTC and/or trained in PROMPT is not medically necessary for treatment of the patients medical condition. The request for speech therapy to be delivered in-home is not medically necessary in this clinical setting as the patient is ambulatory and is not homebound. Therefore, based on the medical literature cited above and the documentation submitted for review, the medical necessity of the requested services has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee requested authorization and coverage of heart catheterization. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees pericarditis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the right ankle for evaluation of the enrollees ankle injury. Findings:  The physician reviewer found that ankle injuries are one of the more frequently injured weight bearing joints in the body.  Considerable research has been performed to best direct diagnostic imaging and eliminate unnecessary studies. Per the medical evidence, it was appropriate for the patient to have had an ankle x-ray, and that x-ray did not detect any bony abnormality or disruption of the ankle mortise (which could necessitate surgery). The diagnosis was that the patient had an ankle sprain.  In general, the only reason to obtain an imaging study is if it will change the course of treatment.  In this patients case, if surgery were a likely immediate option, then there would be support for obtaining an MRI.  Ankle sprains are generally classified as grade 1, 2, or 3.  Depending on the amount of damage or the number of ligaments that are affected, each sprain is classified from mild to severe.  A grade 1 sprain is defined as mild damage to a ligament without instability.  A grade 2 sprain is considered a partial tear to the ligament, and a grade 3 sprain is a complete tear of the ligament. One study published a systemic review and reported balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II, and III lateral ankle ligament ruptures can be managed without surgery. Another study noted stable ankle sprains have a good prognosis while for unstable ankle sprains, conservative treatment is at least as effective as operative treatment without the related possible complications.  In this patients case, there is no advantage in obtaining an MRI study at this time. Regardless of any MRI findings, the patient would still need rest, pain medications, and possibly physical therapy. Final Result: The reviewer determined that the requested services are 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 diagnostic radiology 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 50-year-old male enrollee has requested Viagra (sildenafil) 100mg daily for the treatment of his pulmonary hypertension. Findings:  The physician reviewer found that this patient does have moderate to severe pulmonary hypertension, but it is on the basis of his mitral regurgitation and left ventricular dysfunction and not on the basis of any documented intrinsic pulmonary pathology. This is confirmed by the right heart catheterization results demonstrating severely elevated mean pulmonary capillary wedge pressure (41 mmHg) with very large V wave and no transpulmonary gradient. In this circumstance, specific pulmonary vasodilators, including sildenafil, are not indicated and are not considered standard of care in the medical community. Current practice guidelines that are endorsed by several national organizations do not recommend specific pulmonary vasodilator therapy for treatment of pulmonary hypertension secondary to left heart pathology.