Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. Applying Sections 1317.1(a) and 1317.1(b), a portion of the laboratory testing including lipase, comprehensive metabolic panel, and lipid panel, and the physical examination were provided for the treatment of an emergency medical condition. The patient initially reported symptoms concerning for acute pancreatitis, and elevated triglycerides were found, which can cause acute pancreatitis. A diagnosis of acute pancreatitis requires two of three findings, including symptoms consistent with pancreatitis, elevated lipase greater than three times the upper limit of normal, and/or imaging consistent with pancreatitis (Banks, et al.; Garber, et al.). In order to determine whether acute pancreatitis was present, the patients lipase had to be tested. Additionally, the chemistry panel was appropriate to assess for causes of further causes of pancreatitis, such as biliary obstruction and acute kidney injury (Nassar and Qunibi). These services were appropriate for evaluation of the patients medical condition, which manifested itself by acute symptoms of sufficient severity such that the absence of immediate medical attention would reasonably have been expected to result in placing the patients health in serious jeopardy or cause serious impairment to bodily functions. However, the remainder of the services provided were not provided for the treatment of an emergent medical condition. Moreover, emergent assessment of hemoglobin A1C, microalbumin, thyroid stimulating hormone, and free T4 are not supported for any indication documented in the provided records (Marathe, et al.; Jonklaas, et al.). The services provided on additional dates of service were not required in an emergent fashion as the patients condition was no longer concerning for an acute disease process. Similarly, the services additional dates of service were not urgent care services defined by services to prevent serious deterioration of the patients health resulting from unforeseen illness or injury for which treatment cannot be delayed until the patient returned to the Health Plans service area. For these reasons, the physical examination and laboratory testing including lipase, comprehensive metabolic panel, and lipid panel were emergency medical services, while the remainder of the services were not emergency medical services. 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 internal medicine with subspecialty 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: Overturned

A 58-year-old female enrollee has requested a magnetic resonance imaging (MRI) scan of the coccyx for an evaluation of her coccygeal pain. Findings:  The physician reviewer found that tumors in and around the sacrococcygeal area can present with coccygeal pain. Plain x-rays typically will not be very helpful because of the complex anatomy of this region. A patient presenting with persistent pain in this area warrants further diagnostic investigation and an MRI is likely to be helpful in diagnosing the source of the patients pain and could affect the plan of treatment. The clinical utility of MRI in this setting is well established, and as such, the study should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 64-year-old female with a body mass index (BMI) of 49.1. She has significant clinical comorbidities. The patient has failed monitored weight loss programs. She is a candidate for bariatric surgery and wishes to undergo a Lap-Band procedure. There is no evidence in the submitted documentation the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for the proposed Lap-Band procedure.Review of the relevant medical literature demonstrates there is sufficient evidence to support the use of the Lap-Band procedure for weight loss. The Lap-Band was approved by the Food and Drug Administration in 2001. Morbidity seems to be lower with the Lap-Band procedure than with traditional vertical banding gastroplasty and Roux-en-Y gastric bypass. Additionally, there is generally a slower rate of weight loss with Lap-Band than with Roux-en-Y gastric bypass, which may be beneficial in this case given the patients age. For these reasons, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should obtain psychological clearance before Lap-Band surgery is authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy for management of the enrollees pain during her colonoscopy procedure.  Findings:  The physician reviewer found that there is a lack of documentation of clinical findings that would have required monitored anesthesia care during this patients colonoscopy procedure. The patient was given an American Society of Anesthesiology (ASA) preoperative physical status classification score of 2. A low preoperative physical status classification score of 2 indicates that this patient did not require monitored anesthesia care. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the literature. For all these reasons, the anesthesia services provided during a colonoscopy were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of this patient.  Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 partial hospitalization program (PHP) services and intensive outpatient program (IOP) services for treatment of the enrollees alcohol dependence. Findings:  The physician reviewer found that the patient denied post-acute withdrawal symptoms. The patient  was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive barriers to treatment at a lower level of care. The patient was motivated and demonstrated insight. The patients spouse was supportive of treatment. The patient did not require the intensive treatment of PHP with five days per week contact. In addition,the patient had continued to maintain abstinence since his last use and did not require treatment at the IOP level of care. The patient was engaged in his recovery process and could have been stepped down to an outpatient level of care, with ongoing counseling and community support in the form of AA. The patient no longer required the structure of IOP services. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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 patient is a 36-year-old woman with intractable chronic pain using escalating doses of injectable opiates. She has apparently seen many neurologists and pain specialists without relief. She is moderately well controlled with her current medication regimen. A request has been made for authorization of home injectable hydrocodone, hydroxyzine, and Phenergan. The Health Plan has denied the request on the basis that the requested medications are not medically indicated.Though the requested medications are potent narcotics the patient is under the care of a pain management specialist who has prescribed these medications. The patient has documented severe intractable pain. It has been documented that the patient has failed conservative management efforts. There is also documentation that the requested medication regimen has been successful in relieving the patients pain. Continuation of the requested medications is medically indicated and necessary. A referral to a comprehensive pain management center with expertise in headache should be considered. Based upon the information set forth above, I have determined that the requested medications are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested total right hip replacement surgery for treatment of his medical condition.   Findings: The physician reviewer found that there is documentation of moderate to severe right hip osteoarthritis. Conservative treatment has been limited to medications and activity modification. There is no documentation of participation in the recommended weight loss program or exercise therapy. There is no documentation of response to recent steroid injection. In addition, the peer reviewed literature supports the conclusion that morbid obesity (body mass index greater than 40) confers increased risk for complications and poorer outcomes in total joint arthroplasty, including prosthetic joint infections. In the absence of a trial of weight management combined with physical therapy and/or steroid injections the requested surgery is not indicated. Therefore, total hip replacement surgery is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined 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: Overturned

A 49-year-old male enrollee has requested Lyrica 50mg for treatment of his neuropathic pain. Findings: The physician reviewer found that the efficacy of membrane stabilizing drugs such as Lyrica is a well-established.  In this patients case, Lyrica 50mg has improved his symptoms. Based upon the current medical evidence, Lyrica is a first-line agent that is recommended for use in neuropathic pain syndromes for individuals for patient who do not respond to Neurontin. Lyrica 50mg has been effective for the treatment of this patient with neuropathic pain, and the submitted documentation noted that the patient has experienced a significant improvement in his quality of life since starting this medication.  All told, Lyrica 50mg was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male who presented with back pain of two to three month duration. He underwent workup including CT scan of the abdomen, which showed pancreatic metastases that extend to the aortocaval lymph node. In addition, there were two enhancing lesions in the liver. Further workup including PET scan showed multiple lung nodules. One of the patients providers has recommended that the patient undergo Cyberknife treatment to the pancreas followed by systemic chemotherapy. His medical oncologist recommended systemic chemotherapy rather than Cyberknife treatment.The patient has requested authorization for Cyberknife surgery and is seeking reimbursement for the PET scan that was performed in July 2006. The Health Plan has denied coverage for these services on the basis that they are not medically necessary.This patient has a presumed diagnosis of pancreatic cancer. Workup including CT and PET scans showed possible metastatic disease. Because of systemic disease in the liver and potentially the lung, Cyberknife treatment is not recommended. There is no evidence Cyberknife therapy is likely to be superior to other potential treatment modalities. As such, Cyberknife therapy is not medically warranted for this patient. With regard to the PET scan, this diagnostic modality is not generally utilized in the workup of presumed pancreatic cancer. PET scan is an emerging diagnostic modality without established efficacy in this setting. There is no medical indication or justification for PET scanning in the evaluation and treatment of this patient. Based upon the information set forth above, I have determined the services at issue are/were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Pura-ply for treatment of the enrollees venous stasis ulceration.  Findings: Three physician reviewers found that there is a lack of support for the product at issue in this patients case.  Pura-ply is a dermal substitute which has been approved by the U.S. Food and Drug Administration (FDA) for acute and chronic wound management across a variety of wound types, including partial-thickness and full-thickness wounds, pressure ulcers, surgical wounds, trauma wounds, and venous and diabetic ulcers.  However, there is a lack of long-term, prospective clinical trials which have demonstrated superior outcomes and efficacy compared to existing wound care therapies.  A review of the medical literature indicates that the few clinical trials which have been performed using this product tend to be short-term, industry sponsored and of small sample size.  Thus, there is insufficient clinical evidence to support its use as superior to existing therapies for this patient.  In sum, the superior efficacy of Pura-ply provided has not been established.Final Result: Three reviewers determined that the product at issue was 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: All three physician reviewers are board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for IgE testing (CPT code 82785) and positron emission tomography/computed tomography (PET/CT) of the whole body (CPT code 78816)  for evaluation of the enrollees T-cell lymphoma. Findings:  The physician reviewer found that Serum IgE is a test for a quantitative level of a naturally occurring antibody that can be markedly elevated in patients with T-cell lymphoma along with eosinophilia. This may be diagnostic of a distinct disease with overlap between myeloproliferative disorder and T-cell lymphoma. The test for serum IgE is considered a routine part of the work-up of patients with cutaneous lymphoma. In addition, the requested whole body PET/CT scan to properly stage the patient is supported as medically necessary in this clinical setting. PET/CT scans are indicated to stage patients at initial diagnosis and before the start of systemic therapy. These imaging studies are also indicated to assess the effects of systemic therapy. All told, the requested IgE testing (CPT code 82785) and PET/CT of the whole body (CPT code 78816) are medically necessary for evaluation of this patients cutaneous T-cell lymphoma. Final Result: The reviewer determined that the requested diagnostic procedures are 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 sub-specialty certification in medical oncology 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 Monovisc injections for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Researchers 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, there is a history of relief lasting over a year from prior viscosupplementation. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Monovisc injections (HCPCS code J7327) for both knees are medically necessary for the treatment of this patient.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: Experimental/Investigational
Decision: Upheld

An enrollee has requested an intensive cardiac rehabilitation program for treatment of her myocardial infarction. Nature of Statutory Criteria/Case Summary:  Three physician reviewers found that based on the records provided, the patient presents with a non-ST segment myocardial infarction in the absence of obstructive coronary disease on angiography. In this circumstance of recent non-ST segment elevation myocardial infarction post discharge treatment guidelines have been developed, are periodically updated and are endorsed by several national organizations. These guidelines support use of traditional cardiac rehabilitation. All told, the guidelines do not suggest the requested intensive cardiac rehabilitation program is likely to be more beneficial than standard cardiac rehabilitation services for treatment of this patients medical condition status post myocardial infarction. Final Result: Three reviewers determined that 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.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old female with a history of chronic constipation and difficult defecation. She has had an extensive GI workup which by her account demonstrated colonic stricture, as evidenced by limited passage of the colonoscope and barium enema studies. She has been given a diagnosis of colonic inertia. More recently, the patient has had symptoms of vaginal pain/pressure, lower abdominal/back pain and dyspareunia; she has become concerned that she has endometriosis. A CT scan showed a mildly enlarged heterogeneous uterus consistent with small fibroids as well as normal adnexa and the patients pelvic exam was also described as normal. The patient had been offered a partial colectomy by the surgeon; however, she has requested a laparoscopy to rule out endometriosis as the cause of her symptoms. The Plan gynecologist felt that it was unlikely that the patient had endometriosis and that the risks of laparoscopy would outweigh the benefits. The patients request for authorization of a diagnostic laparoscopy was denied by the Health Plan citing a lack of medical necessity.Although there exists some possibility of endometriosis involving the bowel, the treatment of such would be colectomy; similar to a previous surgical recommendation. If the surgeon believes that a partial colectomy is currently indicated and the patient consents to this surgery, her interests would best be served by first undergoing exploratory laparotomy with both a colorectal surgeon and a gynecologist present. If endometriosis of the bowel is responsible for her symptoms, the patient could then receive the appropriate surgical treatment. At this time, a diagnostic laparoscopy would serve no useful purpose and therefore is not medically indicated. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.