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

Nature of Statutory Criteria/Case Summary:    An enrollee has requested methadone and Norco for treatment of her medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the requested medications has not been established. According to the documentation submitted for review, the patient has been treated with opioids long term without documentation of improved function or attempted weaning. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Moreover, the current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point controlled release narcotics if indicated with close monitoring by a certified pain management physician is recommended. A study reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. For the reasons provided, the patients request for methadone and Norco is not medically necessary.Final Result: The reviewer determined that the requested medications 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 anesthesiology and 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name medication, Norditropin Flexpro 15 mg/1.5 mL (10 mg/mL) pen injector. Studies found that switching between different types of recombinant human growth hormone (rhGH) had no impact on efficacy or safety in children with growth hormone deficiency, and that various rhGH preparations were well tolerated. Current medical literature does not suggest that there is a medical benefit in using one brand over another to treat children with Prader-Willi syndrome. In this case, however, the patient has been successfully treated with brand Norditropin Flexpro. Given the equivalence of efficacy of recombinant growth formulations, and the history of successful use of this formulation, the brand name medication , Norditropin Flexpro 15 mg/1.5 mL (10 mg/mL) pen injector 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, genetic testing was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The 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: Physician reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 and 3 are board certified in clinical genetics and genomics 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the sacroiliac (SI) joint fusion with three day inpatient hospital stay for treatment of her left SI joint arthrosis and left sacral ala and left S1 neural foraminal degenerative cyst. Findings:  The physician reviewer found that based upon a review of the medical records, the primary pathology in this case was S1 radiculopathy due to a 3 cm cyst of the sacrum. The radiculopathy had recurred despite previous surgery consisting of a sacral laminectomy. This necessitated resection of a portion of the sacrum with excision of the cyst which resulted in instability. Given the instability, SI fusion was indicated for stabilization of the SI joint. Although minimally invasive surgery is preferred for the SI joint, in this case, and the pathology was different. Therefore, the stabilization performed was appropriate. The three days hospitalization was necessitated for post-operative pain control and was also reasonable. As noted by researchers, minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. 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: Reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested C5-6 cervical disc arthroplasty (ProDisc) for treatment of his cervical degenerative disc disease. Findings:  Three physician reviewers found that cervical disc arthroplasty is not likely to be more beneficial for this patient than ongoing conservative care and/or fusion. At this time, there are unresolved issues concerning cervical disc arthroplasty. These issues include whether or not improved range of motion will in fact be maintained over time, or whether fibrosis and heterotopic ossification will diminish range of motion over time. There are also unresolved issues with regard to adjacent segment degeneration. It is not clear whether changes adjacent to an area of fusion are determined primarily by intrinsic factors related to cumulative micro-trauma and aging, as opposed to a simpler explanation that disc replacement will decrease compensatory motion at adjacent levels as compared to fusion. The role of posterior facet joint changes is also relevant to this case, as is the effect of intrinsic changes within the spinal nerve roots creating a more diffuse type of syndrome. These factors are not positive prognosticators for cervical disc arthroplasty.In addition, non-case specific issues remain including the long-term implications of cervical disc arthroplasty. These issues include wear-loosening, subsidence, dislocation and re-operation. Concerns have been raised over particulate wear debris and the resultant inflammatory response and will require study over a longer duration of time than has been available to date. At this time, there is insufficient published data to assess the long-term safety and efficacy of cervical disc arthroplasty in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of three to six months of the oral antibiotics Mepron and Zithromax for the treatment of Lyme Disease.  The health plan denied the enrollees request indicating that the requested treatment plan 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 treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested Lamisil for the treatment of his nail fungus. Findings:  The physician reviewer found that the submitted clinical information is unclear in whether this patient has a fungus infection of his nails. There is mention of scrapings being sent for a fungus culture, but no results have been provided. Lifting and separation of the nails can occur in many conditions, only one of which is onychomycosis. The primary care physician did not document a physical exam of the skin and nails in the records provided. In light of the evidence provided, it appears evaluation by a dermatologist would be appropriate. There is not sufficient evidence of a fungal infection to support the use of Lamisil at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested for the prescription medication Mepron for treatment of his babesiosis. Findings:  The physician reviewer found that babesia infection cannot be diagnosed clinically because the symptoms are non-specific. Absent a blood smear, positive serological study or a PCR, the diagnosis cannot be made. Due to the absence of evidence supporting this diagnosis, treatment with Mepron is not clinically appropriate. Evidence of past infection is not a valid basis for treatment, as 50-60% of patients infected with Babesia recover without therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection. The submitted documentation fails to demonstrate the superior efficacy of the requested services in this patients case. Hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patella-femoral syndrome (kneecap pain), or osteochondritis dissecans. Hyaluronic acid injections are not recommended for chondromalacia patella. This patient presents with chronic right knee pain. Clinical examination findings have demonstrated positive patellar grind consistent with imaging evidence of chondromalacia patella. Conservative treatment has included corticosteroid injection, without sustained benefit. The records document chondromalacia patella. The clinical notes do not document evidence-based indications for this treatment, including medial and/or lateral compartment osteoarthritis. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of Synvisc One for this patients condition. Therefore, Synvisc One injection is not likely to be of greater benefit than other treatment options.Findings:  Two of the three physician reviewers found the requested services are 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.Final Result: The reviewers determined that the requested medication is 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: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for RT300 Functional Electrical Stimulating (FES) Therapy System.Findings: Two out of three physician reviewers found that RT300 Functional Electrical Stimulating (FES) Therapy System is not likely to be more beneficial for the enrollee than any available standard therapy.The RT300 FES Therapy System provides passive exercise in individuals with neurological weakness by using topical electrical stimulation leads to activate paralyzed limb muscles to drive a stationary cycle. The data from the medical literature, however, has not demonstrated that use of this device improves function or health outcomes in a clinically significant manner for persons with spinal cord pathology. According to Hofer and Schwab, FES does not promote neurological recovery beyond natural recovery and does not improve cardiovascular health, pulmonary health or other health parameters in a clinically significant manner. FES may help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but this provides no significant health or functional benefit in this clinical setting because the muscle tissue that is gained or spared does not provide any clinical or functional benefit. According to Ong and colleagues, Individuals with spinal cord injuries require multidisciplinary care management to achieve optimal health outcomes. Moreover, Tweedy and colleagues state that health and well-being in this patient population should be promoted with active exercise using volitionally intact muscles and general encouragement of active participation in educational, social, recreational, avocational activities, and vocational activities. In this case, the patient sustained a traumatic injury to his cervical spinal cord. While standard medical care and rehabilitation measures may not resolve a person's neurological impairments due to their underlying spinal cord injury, a FES cycle ergometer, is not proven to improve cardiovascular health, pulmonary health, bony health or other health parameters in a clinically significant manner. The extant data have not demonstrated that this type of device improves health outcomes in any clinically significant manner. Therefore, RT300 Functional Electrical Stimulating (FES) Therapy System is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested equipment is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in physical medicine and rehabilitation. All reviewers 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

A 49-year-old female enrollee has requested bilateral hip resurfacing surgery for treatment of her osteoarthritis.  Findings:  The physician reviewer found that based on review of the available records, hip resurfacing surgery is medically necessary for treatment of this patients osteoarthritis. The scientific data demonstrates that hip resurfacing surgery is an alternative to total hip replacement in young, well selected, active patients. Moreover, the medical literature reports excellent outcomes in terms of implant survival and patient satisfaction. In this patient, the criteria for medical necessity has been met for hip resurfacing surgery based on her young age, normal bone density and lack of large subchondral cysts or evidence of avascular necrosis. All told, the requested hip resurfacing surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left hip surgery (total hip arthroplasty or replacement  CPT 27130). York and colleagues reported that the benefits of the direct anterior technique include enhanced post-operative recovery and respect for all the innervation and vascularization territories. The records provided for review document that this patient is being treated for severe hip pain due to labral tear and unilateral primary osteoarthritis of the left hip. The provider charted that the patient presented with left hip pain that is moderate to severe, depending on activities in intensity and sharp and stabbing in quality. The patients provider has recommended left hip total arthroplasty. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures including any formal physical therapy. Additionally, the magnetic resonance imaging (MRI) of the left hip reported left hip anterior superior labral tear and mild left hip degenerative changes. The records do not document the presence of severely advanced arthritis to support the requested total hip arthroplasty. Therefore, the requested left hip surgery (total hip arthroplasty or replacement  CPT 27130) is not medically necessary for 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services provided. Findings:  The patient has a history of left hip pain for several years. Per the consultation the x-rays show bilateral cam femoro-acetabular impingement deformities and Tonnis 3 severe arthritic changes with cysts in the acetabulum and head of the left hip. The diagnosis was severe left hip osteoarthritis. The  orthopedic report indicated that the patient had severe osteoarthritis of the left hip greater than the right hip. The patient underwent minimally invasive left total hip arthroplasty. The patient has requested reimbursement for surgical services provided. At issue in this case is whether the enrollee received emergency medical services on the date 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 surgical services provided on the date in question were not necessary for treatment of an emergency medical condition. The patient presented with an eight-year history of left hip pain. X-rays showed severe osteoarthritis with cysts in the acetabulum and head of the left hip. There was no emergent medical condition noted in the records submitted for review. Based on the clinical documentation submitted for review, the minimally invasive left total hip arthroplasty performed on the date in dispute was not an emergency medical service. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewers determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician 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.