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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior L3-S1 lumbar interbody fusion followed by posterior L3-S1 fusion with instrumentation. Researchers noted that conservative therapy for patients with degenerative lumbar spondylolisthesis may include physical therapy, epidural steroid injection, and pain medications. The authors noted that if pain and symptoms remain unresolved, surgical options may include decompression alone or decompression and fusion. Researchers described that as a result of decompression, the instability associated with spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints requiring fusion. The records provided for review document that this patient is being treated for lumbar disc degeneration, lumbar radiculopathy, and arthropathy of lumbar facet. The patient reports pain with walking, turning in bed, and sitting. Physical examination revealed normal strength and sensation and pain with straight leg raise bilaterally. The records suggest that the patients pain generator has not been easily identified. In addition, the imaging studies do not support instability in the lumbar spine or severe stenoses that requires surgery leading to intraoperative instability. For these reasons, the request for anterior L3-S1 lumbar interbody fusion followed by posterior L3-S1 fusion with instrumentation 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: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty for the treatment of redundant eyelid tissue.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total disc replacement surgery at L4-L5. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with persistent low back pain radiating into the anterior, lateral and posterior left thigh with some associated left leg and foot weakness. Functional limitations are documented in walking tolerance and activities of daily living. There was reported concordant pain at the L4-L5 level in a discogram in November 2015. She has been diagnosed with lumbar radiculopathy. She has reportedly failed long-term conservative treatment, including physical therapy and epidural injections. She is requesting surgical intervention to include an artificial disc replacement over lumbar fusion as she reportedly desires future pregnancy. Current evidence-based medical guidelines do not recommend artificial disc replacement based on insufficient evidence of its effectiveness on improving patient outcomes. The U.S. Food and Drug Administration (FDA) exclusion criteria include radicular compression syndromes and anticipation of pregnancy within three years. In this case, the actual imaging reports were not provided to confirm single level disease and no nerve root compromise. Given the presence of reported radiculopathy and desire for pregnancy, the medical necessity of the lumbar artificial disc replacement has not been established. There is no compelling rationale presented to support the medical necessity of the requested lumbar artificial disc replacement as an exception to evidence-based medical guidelines and FDA exclusion criteria. Therefore, the requested total disc replacement surgery at L4-L5 is not medically necessary for the 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: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX oncogene testing. Findings:  The physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Genetic testing on thyroid nodules is generally considered standard protocol on fine needle aspirations done on thyroid nodules.  There is sufficient literature to indicate that this test can help avoid unnecessary surgeries.  In this patients case, the initial biopsy came back as indeterminate. ThyGenX oncogene testing was positive and helped to lead to definitive surgical management. In sum, ThyGenX oncogene testing performed was likely to have been superior over other methods of evaluating this patient. Final Result: 3 of 3 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The parent of a 15-year-old female enrollee has requested coverage for continued after school social skills program for socialization training provided five days per week for three hours per day for treatment of the enrollees autism.  Findings:  The physician reviewer found that Autism spectrum disorder (ASD) is a developmental disability that has early core deficits in social interaction and communication. These deficits influence overall development into adulthood. Primary treatment involves psychological and educational interventions that reduce maladaptive behaviors and increase social skills as well as cognitive ability (Maglione, et al). Evidence from research studies including controlled trials finds that specific interventions to improve social skills in children with autism are effective (Bauminger). The guidelines state that, individuals with ASD should be offered interventions specifically targeting deficits in social communication with a focus on social skills (Maglione, et al). This patient has identified social skills deficits and is involved a social skills program with a specific protocol. This therapy should be continued as it is medically necessary in the overall treatment of the patients Aspergers disorder.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested daily Lovenox injections for treatment of her pregnancy. Findings:  Three physician reviewers found that the thrombophilia/autoimmune panel performed after this patients pregnancy loss is a common panel of its type in these situations. However, recent evidence (Branch) disproves any association with any of the common thrombophilias and common adverse pregnancy outcomes, particularly recurrent first-trimester losses. Along these lines, only anticardiolipin antibodies have been definitively associated with recurrent pregnancy loss, warranting prophylactic therapy for pregnancy support consisting of heparin (preferably LMWH) and low-dose aspirin. For other thrombophilias, including the prothrombin gene and factor V Leiden mutations, published data does not support heparin prophylaxis of any type (standard or LMWH) for this indication. Among the potential thrombophilias, the MTHFR mutation has been shown to not be associated with any adverse pregnancy outcomes (ACOG and Said and colleagues). In fact, the study by Said and colleagues suggests that the MTHFR mutation may actually be protective for pregnancy. In addition, as a folate metabolism pathway mutation, there is no biochemical explanation for why heparin would be effective to correct an MTHFR mutation; at most, folate supplementation would be more appropriate biochemically, but not for an individual who was only heterozygous for a mutation. Prevailing opinion is that these MTHFR mutations are actually not abnormalities, but polymorphisms, that is, biologic variants with little clinical impact at all. Therefore, no treatment is indicated for them in this or any context, and the ACOG Practice Bulletin states that they should no longer be tested for. The fact that a different polymorphism for the MTHFR gene was identified heterozygously in this patient than the one in the ACOG paper is not clinically significant; none of these mutations are worse than any other, but some are more common than others. Although prophylactic heparinization with Lovenox would be appropriate if there was documentation of positive anti-phospholipid antibodies in conjunction with recurrent losses, such is not the case with this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old female enrollee requested crown replacement on tooth No. 3.  Findings:  The physician reviewer found that the submitted records do not demonstrate that crown replacement on tooth No. 3 was necessary to alleviate severe pain or to prevent serious impairment.  In cases such as this in which a portion of the porcelain is broken off an existing porcelain-fused-to-metal crown the implant and abutment would be protected.  The patients tooth was not in danger by delaying the procedure.  There was no urgency from a functional standpoint and aesthetic concerns were minimized by the posterior position of the tooth.  While replacement was warranted at some point, it was not dentally necessary that the replacement take place immediately.  Given the absence of evidence of serious impairment, performance of the crown replacement was not dentally necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power wheelchair with accessories. Respiratory insufficiency, cardiac disease, and contractures are common findings of this patients type of progressive myopathy. The disease involves muscles of the face, neck, trunk, and extremities. The records document that the patient has frequent falls and is unable to functionally ambulate. The patient requires a custom power seating and mobility device that enables appropriate positioning, weight shifts, skin protection, fatigue prevention and easy access to gastric tube for feedings. Due to the progressive nature of her disease, consistently propelling a manual wheelchair in a safe, energy efficient and effective manner inside or outside of her home in not expected. The custom power chair with necessary accessories will allow her to function independently at home, school and community settings. Postural support and pressure redistribution will help reduce the patients risk of skin breakdown. Prevention of overuse injuries and fatigue of upper body, trunk, and extremities will improve her access to timely and safe feedings. These improvements will provide a means of independence for school and family functioning, quality of life, and psychosocial development. Therefore, the requested power wheelchair is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services provided. Findings:  The physician reviewer found that 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. The medical services provided were not necessary for treatment of an emergency medical condition. The medical records submitted for review do not support that the services provided were emergent. The patient presented with squamous cell cancer that required treatment with Mohs surgery. Although the surgery at issue was indicated in a timely fashion, the patients medical condition situation was not emergent. As such, there was no emergent medical situation and the patient did not meet the criteria for emergent services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer 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: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 23-year-old female enrollee has requested RT300 functional electrical stimulator (FES) for treatment of her C5-7 spinal cord injury.  Findings:  Two physician reviewers found that the requested RT300 FES device is currently utilized at many inpatient and outpatient rehabilitation centers. There is literature demonstrating that persistent use of this FES device over a long period of time increases muscle mass, improves aerobic conditioning, and may reduce osteoporosis. However, there is minimal literature that shows a meaningful clinical improvement in functional status, enhanced lower extremity function, or recovery of ambulation. In the absence of clinical studies that confirm meaningful clinical benefit, and in the absence of recommendations from leaders as to the utility of this therapy, the requested device is not more likely be beneficial to this patient than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested  for Synvisc injections for treatment of her ankle pain. Findings:  Three physician reviewers found that synvisc injections have not been approved for joints other than the knee. There is insufficient evidence in the medical literature supporting the use of Synvisc or any other form of viscosupplementation for the ankle. Based upon the evidence available to date, the patient is likely to achieve better results with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female is requesting for Orthovisc injections for treatment of her osteoarthritis of the knee.  Findings:  The physician reviewer found that there is no documentation of a trial and failure of nonsteroidal anti-inflammatory drugs or that the patient has attempted an intra-articular corticosteroid injection prior to the requested use of Orthovisc injections. The patient has tried prescription strength ibuprofen. However, there is no documentation of trial and failure of other NSAIDS. It is not uncommon for patients to fail to respond to one or more NSAIDS, but then to have adequate effects from other NSAIDS, particularly when medications from different NSAID classes are used. In addition, there is no documentation of any trials of corticosteroid injections of the knee. Corticosteroid injections are also a reasonable treatment modality for osteoarthritis of the knee, and some patients may notice improvement for extended periods of time.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a six-year-old female enrollee requested authorization and coverage of the medication Vioxx for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic recurrent multifocal osteomyelitis (CRMO).One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

An 18-year-old female has requested services related to an open clinical trial using the anti-angiogenic and anti-lymphangiogenic agent sirolimus and mTOR (mammalian target of rapamycin) inhibitor for treatment of her lymphatic tumor/overgrowth.  Findings:  Three physician reviewers found that the patient has a very rare disorder classified as a lymphatic malformation.  Per the medical records, this is characterized by multiple lytic bone lesions and cystic lesions intra-abdominally, including within her spleen.  This condition has been associated with chronic pain and diarrhea.  In this case, the requested services are likely to be more effective than other available treatment options.  This patient has a very rare condition, and there is no standard of care for its treatment.  Sirolimus is one of a class of mTOR inhibitors which has been approved for use in several cancer types.  One mechanism of action of this medication is to inhibit vascular endothelial growth factor, one of the key regulators of both angiogenesis and lymphangiogenesis.  Accordingly, it has been used in the management of this condition with some success.  In sum, the requested services related to an open clinical trial using the anti-angiogenic and anti-lymphangiogenic agent sirolimus and mTOR (mammalian target of rapamycin) inhibitor are likely to be of greater benefit than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the patient had multiple prior mammograms which were negative, and the records note fatty breasts.  The records do not indicate that breast tomosynthesis would provide additional information which would improve outcome.  Therefore, breast tomosynthesis was not likely to have been of greater benefit than other options for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested radiofrequency neurolysis for treatment of her lumbar facet pain.  Findings:  Two physician reviewers found that the submitted documentation supports the superior efficacy of the requested services in this patients case.  The current medical evidence supports radiofrequency neurolysis in this clinical setting.  Repeat medial branch blocks were performed on the date indicated.  The documentation noted a visual analog scale score of 8 prior to the procedure, and post procedure visual analog scale score was 1-2.  In this case, the provider performed medial branch blocks, with adequate response.  All told, radiofrequency neurolysis is likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient mental health level of care services for treatment of the enrollees schizoaffective disorder and polysubstance abuse.Findings:  The physician reviewer found that the records provided for review document that the patient was not a danger to herself or others. She was not aggressive or violent. Her hygiene and grooming were good, demonstrating the ability to care for herself adequately. She was cooperative and compliant with her medications. She participated in group activities. She experienced no medication side effects. Given her demonstrated stability, there was no reason to believe that there was risk of decompensation or immediate rehospitalization at acute inpatient level of care if she was discharged. The services provided to the patient were custodial in nature. 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 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.