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

The patient is a 56-year-old male with morbid obesity who underwent a lap band procedure in January 2005. The patient lost an initial 30 pounds and has now stopped losing weight. The patient indicates the band is too tight and he is requesting takedown of the band followed by a Roux-en-Y procedure. He has had an outside psychiatric evaluation, but has not completed in-plan counseling. He has arthritic complaints affecting his back and hip. His band has not been adjusted since the procedure was originally performed. The Health Plan has denied authorization for the proposed procedures on the basis they are not medically necessary for treatment of the patients condition.At this point the patient is failing to lose weight with a gastric restrictive procedure. This requires an active effort to reduce intake. This raises clinical concerns as to compliance with a restrictive/malabsorptive procedure that will have more severe metabolic consequences. The urgency in the patients letters implies he is looking for a gastric fix.A full bariatric evaluation as recommended by the Health Plan is medically appropriate and reasonable at this time. The band could be evaluated and adjusted or removed with either concomitant or deferred Roux-en-Y gastric bypass as a part of an overall treatment plan for this patient. This needs to be approached in a programmatic and team-oriented fashion. Since further evaluation is needed, I have determined 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the upper right extremity.According to the American College of Radiology Appropriateness Criteria for chronic elbow pain, an MRI of elbow without intravenous (IV) contrast is usually appropriate when there is elbow pain and x-rays are non-diagnostic in the setting of (1) suspected occult fracture or other bone abnormality, (2) suspected nerve abnormality or (3) suspected collateral ligament tear. In this case, the patient had persistent pain, tingling in fingers, stiffness, swelling, lack of ability to perform certain activities of daily life, along with objectively limited flexion, extension, supination, and pronation elbow movements. This was reportedly despite treatment including splinting, analgesic medications, and anti-inflammatories. Additionally, radiographic studies were inconclusive. The combination of patients lack of detailed-definitive clinical and imaging-corroborative diagnosis led to plausible suspected differential diagnoses including occult bony injury, osteochondral lesion, ligamentous tear and/or nerve injury. There are multiple plausible elbow injuries in this case. Each has significant potential for highly adverse sequelae if not expeditiously fully detected, diagnosed, and treated with an injury-specific protocol. Therefore, an MRI of the upper right extremity is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the evaluation 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

A 54-year-old male has requested Sculptra injections for treatment of his lipodystrophy.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services at this time.  HIV lipoatrophy is a common complication of HIV retroviral therapy.  Sculptra is an established treatment for facial wasting directly related to this therapy.  In general, there is no functional deficit to facial wasting.  Current photographs were not provided in this case.  The most recent photographs provided were from two years ago.  Therefore, the medical necessity of the requested Sculptra injections has not been established at this time.  In this patients case, he has lipoatrophy, which is a known complication of medical treatment.  This is considered to be an abnormal structure of the body, and this is caused by HIV medication in this patients case.  However, because current photographs were not submitted, the degree of abnormality and the patients current condition cannot be assessed.  In this case, the submitted records do not allow for an assessment regarding whether Sculptra injections will offer more than a minimal improvement in the appearance of the patient.  Recent photographs and documentation of current degree of severity are needed to establish the patients current condition.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for transoral incisionless fundoplication procedure utilizing the EsophyX device. Currently, there are limited data supporting a clinical role for transoral incisionless fundoplication in the treatment of patients with gastroesophageal reflux disease (GERD) who may respond to increased proton pump inhibitor (PPI) dosing. Researchers found that at six months, 59% of chronic GERD patients remained in clinical remission after active intervention. Researchers also reported that after a five-year follow-up, the transoral incisionless fundoplication provided safe and sustained long-term elimination of troublesome GERD symptoms. However, the authors noted that there were three reoperations by the end of the five-year follow-up and 34% of the remaining patients were back on daily PPI therapy. This patients records suggest that her condition is not refractory to PPI therapy given the dosing reported in the chart. Accordingly, the requested transoral incisionless fundoplication procedure utilizing the EsophyX device is 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 requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. The Health Plan has denied this request indicating the services at issue were not necessary for treatment of an emergency medical condition.Findings:  At issue in this case is whether the enrollee received emergency medical services on the date(s) 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.EMR of large flat polyps is a complex procedure requiring a high level of technical skill and experience.  In fact, performance of over 100 procedures is required before the learning curve begins to flatten.  Without expert performance, perforation, bleeding, and recurrence can occur, especially in polyps larger than 1 cm.  Furthermore, not all endoscopic mucosal resection procedures are the same.  In this case, the patient had a significantly and unusually large polyp (5-7 cm) that would require surgery in most cases; if a complication occurred, due to the rectal location, surgery would result in an ostomy.  The provider who performed the surgery is one of a few experts on the West coast with experience in endoscopic resection of polyps of this size. Accordingly, the documentation provided supports that the EMR was an emergency medical service. Thus, the patient received emergency medical services on the date of service at issue.Final Result: The reviewer has determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  The reviewer is board certified in 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: The patient has requested authorization and coverage for brand name medication Norco 10-325 tablet. The U.S. Food and Drug Administration (FDA) asserted that, a generic drug is a medication created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. These similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand-name version. Per the Centers for Disease Control and Prevention (CDC) guidelines, Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids . In this case, the patient has chronic pain that has reportedly been treated with generic hydrocodone, and brand name Norco in the past. The patient indicated that the brand name formulation of Norco did not cause the somnolence, nausea, and constipation that she experienced with the generic hydrocodone formulation. She reports that she has used more medication than was prescribed to receive the same analgesic benefit. The reported side effects of nausea, constipation, and somnolence are common side effects of all opioid medications and are not unique to generic formulations of Norco. Based on the medical records for review and the FDA statement on generic drug bioequivalence, the requested brand name medication Norco 10-325 tablet is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 subspecialty certification in pain management 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: An enrollee has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees hepatitis C. The submitted documentation supports the requested medication regimen in this clinical setting. According to recent guidelines, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. Per the guidelines, non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection, regardless of fibrosis stage. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 authorization and coverage for wireless capsule endoscopy. The submitted documentation does not support that the requested service is medically necessary. Enns and colleagues performed a systematic literature search of studies on the use of capsule endoscopy. They concluded that capsule endoscopy should be considered a complimentary test in patients with GI bleeding, Crohns disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies. In this case, based on the limited clinical information provided, there is no indication of the need to perform a wireless capsule endoscopy in this patient. There are no signs or symptoms of unexplained GI blood loss. There is no clinical evidence that the patient has a small bowel neoplasm or other indication for the capsule. Under these circumstances, wireless capsule endoscopy is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested service 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 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

The parents of a six-year-old male who has consistently grown below the 1.2 percentile are requesting authorization of growth hormone (GH) therapy.Reviewers Findings:  The reviewing physician found that given the patients poor growth, the lack of delayed bone age and thus the patients low adult height prediction, the patient is clearly an appropriate candidate GH therapy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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 parent of an enrollee has requested reimbursement for services provided at Second Nature Uintah. Findings:  The physician reviewer found that this patient demonstrated chronic and acute symptoms of multiple comorbidities and polysubstance abuse likely secondary to underline psychiatric illness. As a result of her primary psychiatric illnesses, she experienced severe trauma and demonstrated multiple symptoms typical of trauma including self-harm, impulsive suicidal thoughts and gestures, as well as symptoms of eating disorders and impulsive sexual acting out. She was at risk for recurrent self-destructive behavior including suicidal gestures. The records state that she became suicidal even as she was being transported to the residential treatment center. Patients with substance abuse disorders often meet criteria for other diagnoses and comorbidities. In an effort to prevent relapse for such patients, they should be afforded an opportunity to separate themselves from their former companions who are their enablers. A proper and well-disciplined youth outdoor program can be particularly useful in helping adolescent patients separate themselves from the toxic environment in which they had been using illicit substances. Moreover, the adolescent who successfully completes such a challenging program can effectively reestablish her sense of autonomy, which is critical in recovery from the trauma associated with sexual assault. For these reasons, the services provided at Second Nature Uintah were medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 75 mg every two weeks for treatment of the enrollees hypertension, hyperlipidemia and an elevated coronary calcium score.  Findings:  The physician reviewer found that Tte request for Praluent 75 mg every two weeks has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient is a 62-year-old female with hyperlipidemia, intolerance to statins and Zetia and no documented significant obstructive coronary or carotid disease.  Praluent is a PCSK9 inhibitor studied and approved for patients with heterozygous familial hypercholesterolemia or patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not meet any of those conditions based on the documentation provided. Specifically, there is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL- cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical exam findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee requested speech therapy services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of speech therapy for this patient. The peer-reviewed literature supports speech therapy in this clinical setting. Law and colleagues reported that children with speech delay can be readily and successfully treated, as confirmed in this meta-analysis of multiple medical journal articles. In addition, Goorhuis-Brouwer and Knijff emphasized that normal, as well as cognitively delayed children, are candidates for successful speech therapy. In this case, at 17 months of age this patient had no language, his expressive output was equivalent to the gestures and vocalizations of a 10 month old child. The customary and usual medical intervention for a child with this marked delay in language development would be speech therapy intervention.  The patient should continue to receive one hour of weekly speech therapy as he has made such significant progress with speech therapy at the frequency of one time per week. Therefore, based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition.