Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. On review of the available documentation, this patient presented to the emergency department following a visit that morning with recurrent atrial fibrillation after failing outpatient management. The patient demonstrated hemodynamic instability with a blood pressure drop after administration of metoprolol. The patient received a diltiazem infusion for varying heart rates. The patient could not be discharged home with a diltiazem infusion, so he was admitted. Flecainide was added to the patients regimen, and this allowed the patient to be weaned from the diltiazem infusion. According to medical literatures, diltiazem is associated with a shorter time to rate control than metoprolol. The records document that the patient demonstrated hemodynamic instability and required a diltiazem infusion. Consistent with the medical literature, the services provided to this patient from meet the criteria for emergency medical services as defined by California law. Therefore, the services provided to this patient were emergency services.Final Result: The reviewer determined that the services at issue were emergency medical services for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is experimental for treatment of the enrollees migraine headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed.  Findings:  The physician reviewers found that Lyme disease is an infectious disease caused by bacteria generally transmitted by a tick bite. The most common symptom is an expanding area of redness at the site of the bite known as erythema migraines that often begins about a week following the bite. Other symptoms include fever, headache, joint pain, focal paresthesias, and unusual sites of paralysis. Overall, there is limited value in obtaining a SPECT scan for this patient since regardless of the findings since the ultimate management is primarily based on clinical presentation. All told, the SPECT scan performed 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 diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer s are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

The parent of an 11-year-old male enrollee has requested urgent care services for treatment of the enrollee's swollen bug bite on the left rib area. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the parents circumstances would believe the patient was experiencing an urgent medical condition. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Health Plans service area.This patient was taken to the urgent care center due to a swollen bug bite. Symptoms only included itching, with no mention of pain or muscle cramping. In a letter submitted from the patients parent after the services were rendered, there was mention of concern for a black widow spider bite. The parent noted that their primary care physicians office was closed at the time the urgent care services were sought. However, usual practice for most providers is to have a physician on-call at all times and according to the denial documentation, there was a physician on-call in this case. It does not appear that the physician was contacted prior to the patients presentation to the urgent care center. While it would be reasonable to seek urgent care services for a black widow spider bite, itching alone would not prompt a prudent layperson to suspect such a bite. This patients lesion was noted to be present two days prior to presentation to the urgent care center; symptoms of a serious bite would have developed quickly, and would have been obvious and concerning. Such symptoms would include pain, muscle cramping, weakness, agitation, abdominal pain, etc. Further, there were resources available (i.e., on-call physician) to determine the likelihood that this lesion was sufficiently serious to merit after-hours evaluation. All told, a prudent layperson would not believe that the presence of an itchy bug bite for two days would place the patient at risk of serious deterioration if treatment was delayed.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for proton beam radiation therapy.Findings:  Three physician reviewers found that the requested services are not likely to be more efficacious than other treatment options. Colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy, proton beam radiation therapy, and conformal radiation therapy for prostate cancer. In the comparison between intensity modulated radiation therapy and proton beam radiation therapy, intensity modulated radiation therapy patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between intensity modulated radiation therapy and proton therapy. A position statement released by the American Society of Radiation Oncology (ASTRO) in 2013 stated, At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, proton beam radiation therapy is not likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in radiation 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. In a systematic review of meta-analyses, Campbell and colleagues conducted a systematic review of overlapping meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. In addition, Maheu and colleagues noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. This patient reported consistent relief with hyaluronic acid injections. Given this support, the requested Orthovisc injections are medically necessary for treatment of this patients knee osteoarthritis. 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronic acid injections at 2 units per dose, one dose per week for three doses. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited. The patient has been treated with and failed medications, injections of Depo Medrol, Toradol, and local anesthetics, as well as physical therapy and activity modification. Her pain is chronic, disabling, and sometimes severe. However, there is no indication for surgery. For these reasons, the requested hyaluronic acid injections at 2 units per dose, one dose per week for three doses are medically necessary for treatment of this patient. 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 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

The patient is a 31-year old female who has failed traditional medical care in eliminating or managing her head pain.  The patient reports she has obtained positive results from chiropractic care. The submitted records do not include detailed outcome assessments made by her provider.  The patient has requested that chiropractic care be authorized on an unlimited basis.  The Health Plan has denied authorization for continued chiropractic care on the basis it is not medically necessary.   A diagnosis of cervicogenic headache is one that is often treated successfully with chiropractic care.  Head pain can be a quality of life issue for the patient and it can be difficult for a clinician to achieve and maintain the desired results. Often, co-management is a better approach.  In this case, the patient states she finds chiropractic helpful in providing relief and in improving her quality of life.  By her assessment, the headaches have lessened and become controlled unlike before and she requires less medication.  This patients condition however, is chronic and after the second chiropractic reassessment, she was on a supportive treating schedule. There is no documentation of objective outcome measures being consistently monitored to determine the patients progress. In the absence of such documentation, medical necessity for continued chiropractic care has not been established.The Health Plans alternative recommendation for orthopedic consultation, pain management evaluation and assessment of work and lifestyle for contributing factors is reasonable and those services should be made available to the patient.  Should that approach fail, the patients request for additional chiropractic care should be reconsidered.Based upon the information set forth above, I have determined the requested chiropractic care is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested shoe inserts for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. In this case, the patient presents with first metatarsophalangeal joint  (MPJ) osteoarthritis. The patient has failed conservative treatments including local steroid injections to symptomatic joint, anti-inflammatory medication, bracing, padding, modification of shoe gear, and modification of ambulation. The next logical step in this patients treatment would be custom orthotics with a Mortons extension to reduce the painful motion to the first MPJ. Orthotics have been used to treat first MPJ osteoarthritis for many years and is considered standard of care for this ailment. In this case, the shoe inserts received were medically necessary for this patients medical condition.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in podiatry 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 59-year-old male enrollee has requested continued diabetes care management for the treatment of his diabetes. Findings:  The physician reviewer found that the patients diabetes is under good control. At this point, he does not meet the criteria to enroll in the diabetes care program. Further involvement would not provide additional benefit. The patient should follow-up with his PCP and endocrinologist for further assistance if necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for fecal calprotectin testing. Findings:  Three physician reviewer found that fecal calprotectin testing may be ordered to determine whether inflammation (disease activity), such as inflammatory bowel disease, is present as a cause for gastrointestinal symptoms such as diarrhea.  The use of fecal calprotectin testing to diagnose change in bowel habits has not been subsequently accepted.  The impact of this testing on management and its appropriateness in guiding therapy decisions in patients with unexplained diarrhea has not been demonstrated. The findings can be redundant with standard methods of diagnosis, such as colonoscopy or sigmoidoscopy, or other serum markers of inflammation. Guidelines on the diagnosis and management of diarrhea do not recommend calprotectin as part of the investigation.  Furthermore, clinical studies do not support a standardized action, such as empiric use of antibiotics or empiric therapy for inflammatory bowel disease, for a positive result.  For these reasons, fecal calprotectin testing performed was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 4-year, 9-month-old male enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).  Findings:  Three physician reviewers found that Swedo, a neuropsychiatrist, was one of the first to recognize the possibility of a new syndrome, PANDAS, by an autoimmune attack on the basal ganglia triggered by a streptococcal infection, which could result in motor tics and personality changes. The treatment of choice for these symptoms is IVIG, if the symptom complex meets the criteria of Swedo and colleagues. Despite its similarities to the bodys autoimmune response to beta-streptococcal infection resulting in Sydenhams chorea, the syndrome still continues to be controversial. However, Wolfe and Singer report that many advocates believe in its existence although its diagnosis remains clinical as there are no unequivocal specific confirming laboratory tests. Kirvan and colleagues suggest that the Kirvan/Cunningham test for antineuronal antibodies may be diagnostic of the disorder, but this has not been conclusively established. The reported antibodies returned from Cunninghams laboratory do not confirm the diagnosis of PANDAS in this patient. Overall, the existence of PANDAS is not well recognized by the neurological community. Further, the role for diagnostic testing, if any, has not been established in the medical literature. Thus, the use of IVIG is experimental and cannot be anticipated to benefit this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested breast augmentation for treatment of the enrollees gender dysphoria. The submitted documentation does not support the medical necessity for the requested services in this clinical setting. The patient has been assessed with gender dysphoria. The medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. The surgical concept of breast augmentation in individuals transitioning from the male-to-female gender is well-established and documented within the community of plastic surgeons. However, in this patients case, her examination and photographs depict breast development more consistent with a female than a male. The patient has been treated with hormone therapy and the submitted photographs document the presence of visible breast tissue. The patient has evidence of female breast development. It appears that hormonal therapy has been effective in breast development for this patient. The medical documentation notes a Tanner breast stage of 5, which is consistent with small breasts in an adult female. She has a well-defined inframammary fold and projected breasts. This patient has findings consistent with relatively normal female anatomy and is documented to have had improvement in her gender dysphoria. In this patients case, augmentation mammoplasty would be to enhance the volume and appearance of a relatively normal structure. The surgery would attempt to provide an improvement on a relatively normal female appearance and thus would be consistent with cosmetic surgery. The surgery would not be reconstructive in nature.Findings:The physician reviewer found that the requested services are not medically necessary and are not reconstructive in nature 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

A 55-year-old male enrollee has requested inner ear profusion surgery (or profusion of the round window through the middle ear of one or both ears using a combination of xylocaine and dexamethasone while receiving intravenous xylocaine and dexamethasone) for treatment of his tinnitus.  Findings:  The physician reviewer found that intratympanic lidocaine and steroids have been used in the past for the treatment of tinnitus. Intratympanic lidocaine causes an intense vertigo in all patients treated with this medication via this method (intratympanically). A minority of patients who have been treated with this have had short-term reduction in the intensity of tinnitus. Based upon the available published evidence no patient has had a cure in their tinnitus from this treatment. Furthermore, based upon the lack of evidence concerning safety and efficacy, the requested treatment is not standard medical practice in the otologic community and is considered unproven for the treatment of tinnitus. Vestibular therapy as proposed by the Health Plan has greater potential to benefit the patients condition than the requested treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for a partial nephrectomy performed by a urology oncologist who specializes in kidney surgeries for treatment of her renal cell carcinoma. Findings:  The physician reviewer found that a well-trained urologist should be able to perform a nephrectomy (either partial or total) using an open approach. A urologic oncologist may have additional skills for highly selected diseases and patients, but a partial nephrectomy would not likely fall within this spectrum.