Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX reflux management system for treatment of his gastroesophageal reflux disease (GERD).   Findings:  Two physician reviewers found that  for this patient, the requested procedure is not superior to the available standard therapy for treatment of his medical condition. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu, et al in Curr Opin Gastroenterol). Another evidence review concluded that further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). A peer-reviewed journal published a letter stating that there are 11 reports of endoscopically-confirmed LINX erosion through the esophagus in the publically-accessible FDA adverse events database (Bielefeldt, et al). Additionally, LINX is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al in Surg Endosc). The available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial in this case than standard treatment of surgical fundoplication (Sheu, et al in Surg Endosc). Moreover, the American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on the available literature and relevant clinical guidelines, LINX is not likely to be more effective than other treatment options.  Final Result: Two reviewers determined that the requested procedure 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 50-year-old male enrollee has requested continued inpatient psychiatric care for the treatment of his bipolar disorder, most recent episode depressed, with no psychotic features. Findings:  The physician reviewer found that this patient started to improve after receiving several sessions of ECT and was no longer actively suicidal.  His psychiatrist documented that he was concerned there was no one that would be able to transport the patient to receive ECT on an outpatient basis if he were to discharge the patient. There was some reference in the social work notes of a friend who may have been able to transport the patient, but this was not mentioned in the psychiatrist's notes. There is no mention in the physician progress notes or nursing notes of any active suicidal or homicidal ideation after the date of service in question.  The patient had a clear thought process, no hallucinations or delusions and had independent activities of daily living skills. Disturbances in the above are considered a minimum requirement for continued acute inpatient psychiatric stay. There were no overt psychiatric issues present that necessitated the patient's stay at an acute inpatient level.  Although the patient was benefitting and may continue to benefit from ECT, this could have been safely performed in a less restrictive setting. All told, clinical indications for continued inpatient psychiatric care have not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a weeklong inpatient clinical evaluation including the attendant specialist consultations and tests for evaluation of her skin condition. The physician reviewer found that patients with Crohns disease not only experience symptoms arising from the inflamed bowel but may also be affected by certain extraintestinal manifestations at joints, skin or eyes. Mucocutaneous manifestations of Crohns disease encompass a broad array of clinical findings. These conditions can be challenging to treat, because the skin disease does not always mirror the Crohns disease course. The prevalence of pyoderma gangrenosum in patients with Crohns disease has been estimated to be 0.7% of patients. Clinically, the lesions appear first as erythematous pustules or nodules that progress to ulceronecrotic lesions with granulation tissue, pus, and rolled, violaceus, undermined borders, and are found classically as single or multiple distinct lesions in either a unilateral or a bilateral distributions. The pathergy phenomenon recognized in patients with pyoderma gangrenosum explains the occasional worsening of disease after biopsies or other site manipulations. This patients records document a complex medical problem that requires a thorough systemic work-up to avoid serious complications. The etiology of cutaneous ulceration may be related to her intestinal disease, which may also be the cause of her anemia. All told, the medical literature supports the requested weeklong inpatient clinical evaluation including the attendant specialist consultations and tests as medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Overturned

The parent of a then three-year-old male has requested coverage for past emergency services provided.   Findings:  The physician reviewer found that the patient, a then three-year-old male, was brought to the emergency department with a chief complaint of right earache for two days which woke him from sleep acutely on the day of presentation. He had a history of bilateral ear tubes.  The patients parents had noted bloody purulent drainage from the right ear. Vital signs included temperature 99.9, pulse 132, respirations 28, and oxygen saturation at 98% on room air. The physician noted that the right tympanic membrane showed decreased landmarks and erythema and the patient was diagnosed with otitis media and was prescribed an antibiotic and pain medication.At issue in this case is whether a prudent layperson would have sought immediate medical attention for the patient 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.Review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention for this patient given his symptoms of acute severe ear pain, purulent and bloody drainage from his ear, and history of significant ear problems in the past. The patients symptoms were concerning for serious impairment of hearing and worsening infection. Based upon the severity of the patients symptoms and their sudden worsening in the middle of the night, the parents decision to seek immediate medical attention for the patient was consistent with the response of a prudent layperson in this situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rosuvastatin calcium and Bystolic for treatment of the enrollees coronary risk and non-obstructive coronary stenosis.Findings: The physician reviewer found that the request for rosuvastatin calcium and Bystolic have not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient is a male with coronary risk and non-obstructive coronary stenosis. In this circumstance treatment with a statin medication is indicated and standard accepted practice in the medical community. However, the documentation provided does not support that the Health Plans covered formulary drugs will be or have been ineffective or have been tried and not tolerated. In addition the records provided do not support an accepted medical indication for treatment with a beta blocker medication such as Bystolic. Specifically there is no documented hypertension, angina, prior myocardial infarction, left ventricular dysfunction, tachyarrhythmia or other documented indication for a beta blocker medication. In addition, beta blocker medication can worsen lipid levels. For the reasons provided, the requested medications are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested intravenous antibiotics to be administered via central line (Groshong catheter) for treatment of his Lyme disease.   Findings:  Three physician reviewers found that the patient was bitten by a tick six years ago, and states he developed a rash at that time. He did not seek treatment for the rash. The patient subsequently developed multiple joint pains and fatigue. No other medical history is noted. The patient has subsequently been treated with multiple courses of antibiotics with no effect. No abnormal exam findings are noted. Lyme Western blot IgM and IgG is negative by CDC criteria. No lumbar puncture or synovial fluid analysis is included. Review of the submitted documentation reveals no clinical or laboratory evidence for the diagnosis of late stage Lyme disease. The records demonstrate no evidence for Lyme arthritis or neuroborreliosis. The IgG Western blot should be positive by CDC criteria to consider the diagnosis of late stage Lyme disease. Furthermore, the standard treatment for late stage Lyme disease is 3-4 weeks of intravenous ceftriaxone. There is no indication for further antibiotic treatment in this patient, as there is no evidence to support the efficacy of long-term or repeat courses of antibiotics. In conclusion, the diagnosis of Lyme disease has not been established based upon the documentation provided and long-term or repeated courses of antibiotics have not been shown to be efficacious for the treatment of Lyme disease in the peer-reviewed medical literature.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee requested genetic testing (BRAF Mutation Analysis  CPT 81210 and KRAS Mutation Analysis  CPT 81275) for medical evaluation of her thyroid nodule. Findings:  Two physician reviewers found that In the peer-reviewed medical literature, Alexander and colleagues concluded of their study that a gene-expression classifier can be used to identify a subpopulation of patients with a low likelihood of cancer in a population of patients for whom diagnostic surgery is otherwise recommended. Since each clinical decision must be individualized, these data suggest consideration of a more conservative clinical approach for patients who have nodules with indeterminate cytologic features on fine needle aspiration and a benign result on gene expression classifier testing. Given this clinical support, genetic testing (BRAF Mutation Analysis  CPT 81210 and KRAS Mutation Analysis  CPT 81275) was appropriate and likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested for mental health inpatient adolescent treatmentfor treatment of the enrollees autism and mood disorder.  Findings:  The physician reviewer found that this patient presented with major co-morbid disorders, i.e., autism spectrum disorder and mood disorder including a positive family history of bipolar disorder.  Severe functional impairment was evident.The level of care provided was consistent with Child and Adolescent Level of Care Utilization System criteria and American Academy of Child and Adolescent Psychiatry practice parameters.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female with chronic low back pain due to degenerative disc disease. She has tried conservative measures including pain medication, muscle relaxants, antidepressants, neuroleptic medications, SI joint injections and physical therapy, without lasting relief. Her provider has recommended a spinal cord stimulator. The Health Plan has denied authorization for the device on the basis that it is not medically necessary.There is no Class I data to establish the efficacy of spinal cord stimulators for the treatment of discogenic or non-specific low back pain. The device is not within the mainstream of care for orthopedic practice. Available data does not demonstrate an advantage to spinal cord stimulators over standard pain management modalities. Therefore, I have determined that the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for methadone. Findings:  The physician reviewer found that while methadone has been used as second-line therapy for moderate to severe chronic pain, the documentation does not support the medical necessity for this medication. Methadone has the potential for adverse effects including respiratory depression and adverse cardiac events. Per the Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines, providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Additionally, providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. Furthermore, the CDC recommends that if benefits do not outweigh harms of continued opioid therapy, providers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. There is no evidence of electrocardiogram (EKG) monitoring in this patient during her course of methadone treatment, evidence of significant objective and measurable functional improvement on methadone, or significant objective measurement of pain relief on methadone at the 30 mg daily dose. The documentation does not reveal that a pain management physician has been prescribing the patients methadone or the results of a first-line trial with Desipramine. Thus, the requested methadone is not supported as medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for carotid duplex scan performed for evaluation of the enrollees screen test. Findings: The physician reviewer found that according to the records provided, this patient did not have clinical signs of carotid disease including a lack of bruit. Moreover, there was no clinical history to indicate transient ischemic attack or neurological deficit. There is a lack of support in the documentation for the services at issue. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Serostim. Findings:  The physician reviewer found that wasting, or cachexia, is a debilitating complication of human immunodeficiency virus (HIV). Cachexia is associated with reduced strength and functional ability, as well as a decreased ability to withstand opportunistic infections. The U.S. Food and Drug Administration (FDA) has approved Serostim, a recombinant human growth hormone for treatment of HIV-related cachexia. In addition, clinical studies support a role for Serostim in this clinical setting. The provider in this case noted that an alternative form of hormonal replacement with testosterone is not optimal for this patient, whose testosterone level is currently therapeutic. Therefore, the use of Serostim for the treatment of HIV-related cachexia is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication 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 allergy and immunology 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

The patient is a 21-year-old male who is status post knee surgery. He has requested reimbursement for a cold therapy unit that was used following the procedure for pain control. The Health Plan has denied the patients request on the basis that the efficacy of the cold therapy unit has not been established. The Health Plans denial should be upheld. A cold therapy unit to maintain temperature following knee surgery for pain control has not been proven to be effective in the peer-reviewed literature. To date, there is insufficient data establishing the efficacy of the device at issue. The patient could have been appropriately treated with standard modalities. Therefore, I have determined that the device at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested an osteochondral knee allograft for treatment of his knee pain. Findings:  Two physician reviewers found that based on the peer-reviewed literature, the requested osteochondral knee allograft is not likely to be more beneficial for treatment for the patients medical condition than any other available treatment.  He has multiple lesions and has failed multiple surgical procedures involving the left knee.  The records do not include an up-to-date clinical evaluation of this patient with radiographs to indicate his current status.  Therefore, the requested osteochondral knee allograft is not likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.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.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested authorization and coverage of continued physical therapy for the treatment of cervical strain. 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 upheld the health plans denial on the basis that the requested physical therapy is medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-seven year-old male who underwent arthroscopic subacromial decompression, acromioplasty, glenohumeral debridement, labral resection, synovectomy and manipulation of the right shoulder is requesting authorization for continuous passive motion machine.  Reviewers Findings:The reviewing physician found that the orthopedic community has long recognized the benefit of early range of motion following joint surgery and the use of the CPM machine in this instance was medically appropriate.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A Seventeen year-old female diagnosed as having bipolar affective disorder is requesting coverage of psychiatric residential care. The patient has had a number of inpatient admissions prior to the most recent psychiatric hospitalization.Reviewers Findings:The physician reviewer found that the submitted clinical records demonstrate that the patient has an extensive history of mental illness and is not ready to be transferred to a lower level of care.  The physician reviewer found that the Health Plan denial should be overturned.