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

The patient is a 36-year-old female with diabetes mellitus type 2.  Her blood glucose levels were poorly controlled on metformin and Actos.  The patients hemoglobin A1c was 7.2% in August 2005 while taking metformin and 7.4% while taking Actos.  In December 2005, after a trial of Byetta, she and her endocrinologist assert that monitored blood glucose values improved tremendously. The patients hemoglobin A1c was 6.1% in March 2006, suggesting that she had obtained better blood glucose control.  The patient has requested authorization and coverage for continued treatment with Byetta. The Health Plan determined Byetta was not medically necessary, and denied her request.Patients who are not well controlled on oral agents generally progress to insulin therapy.  Byetta is at least as effective as insulin in improving blood glucose control.  Byetta may have an added advantage for an obese patient, as it is associated with weight loss, not the weight gain that frequently results from treatment with insulin.  Byetta is indicated as adjunctive therapy to improve glycemic control in patients who are taking metformin, a sulfonylurea, or both, but have not achieved adequate blood glucose control. This patient was not well controlled on metformin or Actos as demonstrated by hemoglobin A1c values greater than 7%.  When Byetta was added to these agents, her blood glucose values dramatically improved and her hemoglobin A1c dropped to 6.1%.  The improvement in the patients blood glucose control demonstrates the medical necessity of Byetta in this case.  Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested for a full body PET/CT scan for evaluation of his multiple myeloma.   Findings:  Two physician reviewers found that the fact of the matter is the initial PET scan now serves as a baseline for tumor involvement, and PET/CT scanning is a reasonable exam to monitor treatment response. A follow-up PET/CT scan is reasonable and indicated in this particular patient
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Durolane injection of the right knee. The enrollee has osteoarthritis of the right knee. Her physician reports she has tried and failed various treatments, including Supartz, Kenalog, and naproxen sodium. She has pain going up and down stairs. She is requesting Durolane (hyaluronic acid) injections to the right knee. The enrollees physician states the goal of treatment with Durolane is to decrease pain, maintain or improve joint movement, and limit the loss of joint function. The literature summarizing the hyaluronic acid injections, such as Durolane, is well documented in the American Academy of Orthopaedic Surgery guidelines. In general, the use of hyaluronic acid is not supported in the literature due to the fact that most studies show it does not show superiority over other treatments, including placebo.  The studies in which some people reached a statistical improvement usually did not meet minimally clinically important difference criteria. The enrollees physician indicates that, since steroids injections did not work, the enrollee is a candidate for Synvisc-One.  However, this conclusion has not been demonstrated in literature. While it is discussed as a treatment for people who have failed steroid treatment, it is not evidence that hyaluronic acid injections would work.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for home health nursing visits of 30 minutes once a week.Medical literature stated, Patients outcomes who managed with VAC therapy were better than the other group who managed with the traditional wound dressing. Medical literature also stated, VAC was more effective than wet to moist dressings in terms of reduction in wound surface, depth and degree of granulation tissue formation. VACs thus can be usefully employed for achieving speedy wound healing. In this case, the patient underwent VAC therapy for treatment after evacuation of the infected hematoma of his right lower leg. During the VAC application, he was reported to have difficulty with activities of daily living and to require an assistive device, special transportation, or another person to leave home. The wound VAC was discontinued after an evaluation by the provider stated that wound VAC was no longer necessary. The patient required home health care when he was disabled from a VAC on his leg wound because he had difficulty with activities of daily living and required an assistive device, special transportation, or another person to leave home. The VAC was able to be discontinued in mid-April 2021. While the wound was not completely healed, there is no report or documentation that he continued to have difficulty with activities of daily living, was unable to change his dressings, or was unable to attend physician visits for wound care. Therefore, the requested home health nursing visits of 30 minutes once a week are not medically necessary to treat the patients medical condition.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 plastic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spine surgery for treatment of the enrollees low back pain. Findings:  The physician reviewer found that Evidence based medical guidelines and peer reviewed criteria have not been met in this patients case. Current evidence based medical guideline criteria for lumbar decompression include symptoms/findings that confirm the presence of radiculopathy and correlate with clinical examination and imaging findings. Guidelines do not recommend lumbar fusion for patients with degenerative disc disease, disc herniation, spinal stenosis without degenerative spondylolisthesis or instability, or non-specific low back pain. Fusion may be supported for segmental instability (objectively demonstrable) including excessive motion, as in isthmic or degenerative spondylolisthesis, surgically induced segmental instability and mechanical intervertebral collapse of the motion segment and advanced degenerative changes after surgical discectomy. Preoperative clinical surgical indications require completion of all physical therapy and manual therapy interventions, x-rays demonstrating spinal instability and/or imaging demonstrating nerve root impingement correlated with symptoms and examination findings, spine fusion to be performed at one or two levels, psychosocial screening with confounding issues addressed, and smoking cessation for at least six weeks prior to surgery and during the period of fusion healing.  This patient presents with persistent severe low back pain radiating into the right lower extremity in a reported L3/L5 distribution. The patient reported significant functional difficulty in her daily activities. Detailed evidence of at least six months of reasonable and/or comprehensive nonoperative treatment protocol trial and failure have been submitted. However, there are no clinical findings of nerve root compromise correlated with imaging evidence of degenerative disc disease at L3/4 and L4/5. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion or imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability that would necessitate fusion. Potential psychological issues are documented with no evidence of a psychosocial screen. For these reasons, the requested spinal surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 orthopedic surgery with expertise in spine 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for Rinvoq 15 mg extended release (ER) tablets. In this case, the records show that the patient has been tried on several biologic agents in the past. However, it is not clear that the patient has had dose optimization or that the clinical criteria for therapy failure were truly met. One reasonable path is to reintroduce previously used agents such as vedolizumab alone or in combination with another agent or immunomodulator. During retreatment there is the opportunity for therapeutic drug monitoring, prospective assessment as to whether therapy is truly failing, and for using objective endoscopic, radiologic, and biomarker data to determine success or failure. While notes reported that the patient has not yet been exposed to Janus kinase (JAK) inhibitor therapy, there is a lack of data in current medical literature from phase 3 studies regarding their use in the treatment of Crohn's disease. Therefore, Rinvoq 15 mg ER tablets are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Rinvoq 15 mg ER tablets are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested left knee decompression including bone marrow aspiration and concentration and injection into lesion (29881, 29887 and 20610) for treatment of her medical condition. Three physician reviewers found that the current medical literature supports the use of joint preserving procedures, including core decompression with concentrated bone marrow cells, for the treatment of secondary avascular necrosis in young patients.  The medical evidence supports joint preservation surgery over total knee replacement for young patients with secondary osteonecrosis of the knee.  This patient has been diagnosed with avascular necrosis of both knees, likely due to corticosteroid use for her chronic Crohns disease.  The records include documentation of a comprehensive nonoperative treatment protocol trial and failure.  She meets the criteria to proceed with joint preservation surgery to treat her secondary osteonecrosis and avoid total knee replacement surgeries.  Core decompression with concentrated bone marrow cells is supported as a treatment option for her diagnosis.  All told, the requested left knee decompression including bone marrow aspiration and concentration and injection into lesion is likely to be superior over other treatment options.  Final Result: Three 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 orthopedic surgery 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

A 23-year-old male enrollee has requested acute inpatient psychiatric treatment for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  On admission, the patient denied suicidal, homicidal, or psychotic ideation.  He denied a history of suicide attempts.  Throughout his hospitalization, the patient did not demonstrate withdrawal symptoms.  Per the medical records, his vital signs remained stable.  There was no evidence that he was unable to care for himself.  His psychiatric comorbidities of anxiety and mood disorders were managed on medications, and he tolerated the medication changes made without difficulties.  The patients therapist reported that he developed insight into his difficulties.  Based upon the records, acute inpatient psychiatric treatment was not medically indicated.  The patient did not require 24-hour monitoring at an acute inpatient level of care and could have safely been treated at a lower level of care.  All told, acute inpatient psychiatric treatment was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested Bionicare device and monthly replacement stimulator pads for treatment of her right knee osteoarthritis.  Findings:  Three physician reviewers found that currently there are insufficient high-grade peer-reviewed data to establish the effectiveness of the pulsed electrical therapy device including the Bionicare, with respect to the symptoms, course of knee OA, or outcomes such as subsequent need for joint arthroplasty. The published literature in support of these devices has generally been preliminary in nature (Zizic, et al). More recently, McCarthy and colleagues conducted a systematic review, which identified five randomized, placebo-controlled trials evaluating pulsed electromagnetic field therapy (PEFT). The authors concluded that, There appears to be clear evidence for the recommendation that PEMF does not significantly reduce the pain of knee osteoarthritis. Similarly, in a study in 2010 by Ozguclu and colleagues, the researchers further noted that, The results of this study show that PEMF does not have additional effect on the classical physical treatment in reducing symptoms of knee OA. For these reasons, as well as the recommendations from the American Academy of Orthopaedic Surgeons (AAOS), which do not include pulsed electrical stimulation therapy in their standard protocols for treatment of knee OA. Accordingly, the use of the Bionicare device has not been shown as likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female who has a body mass index (BMI) of 36. Her comorbid conditions include hypertension, exertional dypsnea, hypoglycemia, joint pain, sleep apnea and urinary stress incontinence. She has requested authorization for gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.Based on the patients BMI of 36 and her comorbid conditions, she does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure is 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: The parent of an enrollee has requested plasma rich platelet (PRP) injection for treatment of the enrollees right elbow pain.  Findings: Three physician reviewers found that the current medical literature pertaining to PRP use in sports medicine for nonsurgical therapy of tendinosis does not indicate the requested PRP injection is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The consensus is that more clinical studies are needed to evaluate the use of PRP as an orthobiologic treatment. There is currently insufficient evidence to support the use of PRP in the treatment of musculoskeletal soft tissue injuries such as ligament, muscle, and tendon tears and tendinopathies. Moraes and colleagues review included 19 small single center trials, 17 randomized and two quasi-randomized trials, and with 1,088 participants. The authors compared PRP with placebo, autologous old blood, dry needling, or no PRP therapy. These trials covered eight clinical conditions which included shoulder, elbow, and knee conditions. Tendinopathies were injected with PRP in five trials. The authors concluded that there is currently a paucity of evidence to support the use of PRP for treating musculoskeletal soft tissue injuries. Thus, the requested PRP injection is not likely to provide this patient with a superior health outcome when compared to standard available therapies.Final Result: Three reviewers determined that the requested service is 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 certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg/2 mL pen for treatment of the enrollee who has been evaluated for short stature. Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this patients case. The height data available for this patient is between 8 and 12 years of age, which indicated that he grew at a normal velocity and with an absolute height slightly below the 10th percentile. The fall off in height velocity appears to have occurred somewhere after age 12. His ongoing height velocity of around 4 cm per year is consistent with what is commonly observed in patients with short stature on the basis of constitution delay. The available laboratory data does not support a diagnosis of growth deficiency with a testosterone level of 22. This level is consistent with the very earliest indication of entry into puberty. Additionally, the bone age determinations obtained to date indicate a normal, within the lower half of normal, adult predicted height relative to the genetic target. In sum, this patients growth pattern is not supportive of growth deficiency. Growth hormone therapy would not be recommended, at this time. Based on the medical literature, the benefits from exogenous GH is either nonexistent or unlikely to be discernible above and beyond what growth this patient will do on his own. Importantly, given the last bone age data, the prediction is that the height velocity will increase spontaneously as expected in the next few months.  In this context, it is very unlikely that exogenous growth hormone would lead to any discernible benefits. Final Result: The reviewer 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: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested cortisone injections into the third digit of her right hand for the treatment of her osteoarthritis. Findings:  The physician reviewer found that it is not uncommon in orthopedic clinical practice to give cortisone injections for arthritic pain. Clinically, these injections can be expected to provide relief for three to six months. Cortisone injections do have anti-inflammatory effect, and thus, are most appropriately given in the presence of inflammation. The submitted clinical evidence does not demonstrate the patient is currently experiencing inflammation. Furthermore, there are recognized complications of cortisone injections including tendon weakening, subcutaneous joint atrophy and possible damage to cartilage and surrounding tissues. As such, cortisone injections into joints should be limited to no more than three per year for any indication and should not be provided in the absence of documented inflammation in the affected joint.
Appeal type: Urgent Care
Decision: Upheld

A 55-year-old male has requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department with a chief complaint of flu-like symptoms for a duration of three days, which consisted of generalized body aches, intermittent headache, a mild cough and nasal congestion. The day prior to his emergency room visit, the patient reported that he had a fever up to 100.3 degrees. The records indicate the patient endorsed his pain level as 4 on a scale of 10. It was also noted in the records that the patient had just returned from a trip to India and was concerned that he may have contracted a disease while traveling  abroad. The provider ordered lab tests and a chest x-ray. The lab tests revealed that the patient had influenza-B and the chest x-ray was negative for pneumonia. The patient was treated with ibuprofen 600mg orally in the emergency room and was discharged to home with a prescription for Tamiflu.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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 patient did not have a high fever, severe pain or a severe cough. Therefore, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.