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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Monovisc injection. Findings: 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 indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient had tried and failed other conservative treatments, such as corticosteroid injections. They have status post left knee arthroscopy. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Monovisc injection in the left knee was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 30-year-old male enrollee requested substance abuse intensive outpatient program level of care for treatment of the enrollees alcohol dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  Although the patient has a significant alcohol use disorder, the documentation provided does not support the medical necessity of the intervention.  A comprehensive treatment plan and thorough intake note were included in the medical records, but daily progress notes and serial assessments were not provided.  Thus, there was no means to assess the patients clinical progress or the appropriateness of the service.  Considering the documentation, and the fact that the patient started an anti-craving medication, had a supportive family, and was described self-motivated for treatment and recovery, the substance abuse treatment services provided at the intensive outpatient level of care are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in dermatology and 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld

A 49-year-old male enrollee has requested Biaxin for treatment of his diagnosis of Lyme disease.  Findings:  The physician reviewer found the records indicate the patient presents with fatigue, cognitive dysfunction and arthralgias of several years duration. He has received multiple courses of antibiotics for extended periods of time with some temporary relief of symptoms. The patient has CVID based on borderline low immunoglobulin levels. He has not demonstrated recurrent other infections. The patient has negative Lyme titers in blood and cerebrospinal fluid. All imaging is negative. There was one culture that was positive a number of years ago for spirochete. However, based on these records, it is not clear that the patient has late stage Lyme disease. He does not demonstrate evidence for Lyme arthritis or neuroborreliosis, which usually have immunoglobulin positivity in an IgG pattern. In addition, the medical literature has not established that CVID precludes an antibody formation in Lyme disease. Further, repeated courses of multiple antibiotics have not resulted in any long-term, meaningful clinical improvement or resolution in the literature. In cases of late stage Lyme disease, the standard of care is one, three-to-four week course of intravenous antibiotics with Ceftriaxone. The diagnosis of late stage Lyme disease is not supported and in cases of established diagnosis, one course of intravenous antibiotic is the standard treatment. The requested treatment of Biaxin is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested consultation with a pain management specialist for treatment of her chronic lower back pain, degenerative disc disease, and rheumatoid arthritis.  Findings:  The physician reviewer found that the clinical documentation submitted for review indicates the patient was diagnosed with arthritis at the age of 12. In addition, the providers notes indicate the patient has pain of a 9/10 in the low back. There was documentation of a failure of conservative care including medications, injections and the use of a cane. Given these findings, the requested referral for a consultation with a pain management specialist is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a chest computed tomography (CT) scan (CPT 71250) for evaluation of her medical condition.  Three physician reviewers found that the requested services are likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The peer-reviewed literature supports the requested services in this clinical setting.  According to Ma and colleagues, there is sufficient support for the requested services in this patients case.  All told, the requested chest CT scan is likely to be of greater benefit than other modalities for evaluating this patient. Final Result:  Three reviewers determined that the requested services are 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: All three reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services. Prior to admission, the patients provider stated that patient required the RTC level of care due to the patient being unable to get out of bed and thus would be unable to attend any outpatient treatment including therapy and medication management. However, a lengthy note prior to admission stated that the patients depression was quite a bit reduced from what testing is showing. The records did not demonstrate that the patient was unable to function because she could not get out of bed. When the patient arrived, the patient was calm and cooperative. She was able to participate in treatment. She has no history of suicide attempts. The patient did not have substance use problems at the time of admission. The records indicate that the patient was capable of attending outpatient treatment. The patient does have medical issues, but these medical issues did not require 24-hour supervision. It is standard of care to treat the patient in the least restrictive environment possible. Based on the available documentation, the patient could have been set up in a group home situation and could have attended intensive outpatient treatment. For these reasons, the residential treatment services were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with expertise 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested occipital nerve stimulation for treatment of her medical condition.  Findings:  Two physician reviewers found that this patient has been treated with multiple prophylactic medications which are reasonably expected to offer efficacy in reducing headache frequency and severity.  There are controlled studies demonstrating efficacy of occipital nerve stimulation in the clinical situation of chronic migraine or chronic daily headache.  Per the clinical documentation, occipital nerve stimulation is more likely to offer a meaningful clinical response compared to any other existing standard treatment.   Final Result: Two reviewers determined that the requested services are 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: All three reviewers are board certified in neurology and are actively practicing. Al 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for oral surgery (tooth extraction).There is sufficient support for the service at issue in this clinical setting. Management of an unerupted tooth can prevent complications, such has development of cysts and resorption of adjacent teeth. The treatment provided was indicated for development of a harmonious dental arch and dental occlusion. Per the American Association of Oral and Maxillofacial Surgeons, an impacted tooth is one that cannot erupt into normal position or function and is considered to be pathologic. In this case, the patient had an unerupted tooth with ectopically positioned supernumerary tooth. Given that the tooth failed to erupt, treatment was necessary with the goal of preventing future pathology and optimizing dental and occlusal status. Thus, the oral surgery (tooth extraction) was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in oral facial and maxillary 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

A then 52-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients primary presenting symptom was a sore throat. The medical records do not substantiate the patients contention that he was experiencing severe ear pain. Sore throat is a common affliction treated by most adults with home remedies or by primary physicians. Sore throats are caused by viruses in the vast majority of adults. The patient contends that his condition, exudative pharyngitis, was more severe than a simple sore throat and required immediate medical attention. Exudative pharyngitis is a sore throat with the presence of pus or other thick drainage. It is not a condition that would cause a prudent layperson to believe that the absence of immediate medical care would result in serious jeopardy to his health, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.   It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been superior over other treatment options.  Final Result: All three 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: All three reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested cell function assay laboratory testing for evaluation of her status post cardiac transplant.  Findings:  Three physician reviewers found that the superior effectiveness of the testing at issue has not been established.  At this time, there is a lack of consensus on the utility of the testing at issue in this clinical setting.  The current guidelines do not recommend cell function assay laboratory testing in this patients case.  The data does not support routine use of the testing at issue to guide or monitor therapy.  Therefore, cell function assay laboratory testing is not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested  coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the patient appears to have made modest improvements in his speech and socialization skills while receiving 20 hours per week of ABA therapy over a 9-month period. Due to the patients slow progress, an increase to 25 hours per week of ABA therapy was recommended. The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy have demonstrated significantly improved behavioral outcomes as compared to autistic children who did not receive ABA therapy (Myers, et al.). Additionally, ABA therapy has been proven to be effective in multiple controlled studies. This patient has been diagnosed with autism and ABA therapy remains the documented therapy of choice. However, there is limited evidence regarding the age at which ABA therapy should be discontinued. Generally, ABA therapy is slowly tapered beginning around the age of eight. In the case of this patient, it is medically necessary that ABA therapy be continued and all ABA therapy services provided from the date in question to the present should be reimbursed. However, due to the patients age, ABA therapy should begin to be tapered and therefore, continued ABA therapy at a frequency of 15 hours per week would be appropriate and medically necessary for a minimum of one year with re-evaluation at the end of that period. Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old male enrollee has requested reimbursement for laboratory testing,codes 83890, 83896, 83898 and 83912, for evaluation of the enrollees abdominal pain. Findings:  Two physician reviewers found that Celiac disease is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. This can result in typical malabsorption syndrome (chronic diarrhea, weight loss and abdominal distention) and a spectrum of symptoms potentially affecting any organ or body system, including chronic abdominal pain and constipation. Fasano and Catassi (2005) recommended the use of serological genetic celiac disease tests in order to identify these cases in a timely fashion to prevent serious complications secondary to untreated celiac disease. Underdiagnosis and misdiagnosis of celiac disease are common and can result in protracted and unnecessary morbidity. Hin and colleagues reported that serological screening uncovers a large proportion of patients with this condition and should be considered more frequently, especially when there is a family history of celiac disease.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee requested intensity modulated radiation therapy (IMRT) for treatment of his skin cancer.  Findings:  The physician reviewer found that skin cancer arising from the forehead, in which the course of the nerves are treated to the base of skull, such as in this case, is a head and neck cancer, for which IMRT is considered the standard of care. The radiation target in the treatment of the forehead and base of skull is a complex shaped volume for which IMRT is well-suited. Moreover, IMRT is likely to improve the dose coverage and dose homogeneity. Based on the medical literature and clinical documentation provided for review, IMRT is medically necessary and the most effective way to treat this patient and spare the surrounding normal tissues.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dynasplint for the right elbow. This patient is being treated for stiffness, or contracture, of the right elbow. He underwent right elbow reconstruction and right elbow excision of heterotopic ossification contracture. Occupational therapy notes conclude that he has plateaued with forearm supination despite active therapy. The patients supination fluctuated from 40-50 degrees for three weeks and he has not moved greater than 50 degrees of supination. Current, published peer-reviewed medical literature supports the use of a Dynasplint dynamic splint with noted improvement with range of motion with use of the device. Lindenhovius and colleagues concluded that post-traumatic elbow stiffness can improve with exercises and dynamic or static splinting over a period of six months to one year. Veltman and colleagues reviewed eight randomized and cohort studies and found evidence of improvement with either static-progressive or dynamic splinting for post-traumatic elbow stiffness regardless of specific etiology. For these reasons, the requested Dynasplint for the right elbow is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Dynasplint for the right elbow is 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 device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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.