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

A 63-year-old female enrollee has requested a portable oxygen concentrator (as opposed to an oxygen tank and portable tanks) for treatment of her chronic obstructive pulmonary disease. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  There is a lack of support for the requested equipment in this clinical setting.  Per the submitted records, the patient has a portable system.  As noted in the submitted documentation, a portable system was being used during the office visits in the months specified.  The records do not show that the requested portable oxygen concentrator is needed in this case.  All told, the requested portable oxygen concentrator (as opposed to an oxygen tank and portable tanks) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee requested authorization and coverage of a CT scan for the treatment of an 8 mm well circumscribed left upper lobe lung nodule.  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 service is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested laparoscopic paraesophageal hernia repair and gastrointestinal endoscopy for treatment of his obesity and hiatal hernia. The physician reviewer found that this patient is morbidly obese and meets all standard nationally accepted criteria for bariatric surgery and was approved for laparoscopic Roux-en-Y gastric bypass. In addition, the patient was found to have a hiatal hernia on endoscopy. The provider has recommended surgical repair. While there is no CPT code for laparoscopic hiatal hernia, the most appropriate CPT code for use is 43281, which is laparoscopic paraesophageal hernia repair without mesh. A concomitant hiatal hernia identified pre-operatively or intraoperatively of moderate size should be repaired regardless of the presence of symptoms to prevent secondary complications of worsening or new onset gastroesophageal reflux, increasing hiatal hernia and herniation of the gastric pouch. The laparoscopic concomitant repair of the hiatal hernia is considered medically necessary as a secondary procedure with modifier 51. However, the use of an endoscopy for leak test and evaluation of bleeding is not considered a necessary component of the procedure. Moreover, the current medical literature does not support the need to utilize endoscopy to perform laparoscopic Roux-en-Y gastric bypass. The endoscopy is not considered a separate or secondary billable procedure but part of the method the provider uses to perform laparoscopic Roux-en-Y gastric bypass. Consistent with these findings, the requested laparoscopic paraesophageal hernia repair is medically necessary for treatment of this patients medical condition, but the gastrointestinal endoscopy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in general surgery with sub-specialty certification in minimally invasive and bariatric 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 38-year-old female enrollee has requested radiofrequency ablation (RFA) of uterine fibroids for treatment of her symptomatic uterine fibroids.   Findings:  Two physician reviewers found that this patients records do not establish that the cause of her pain is related to the fibroids or that other possible sources of her symptoms have been ruled out. Further, the patients medical records do not document that she has been treated with available standard therapies and the outcome of those trials. Consistent with these findings, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services received. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates 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 patient was discharged in stable condition from the hospital prior to the dates in question. For the dates of service in question, the patient received laboratory work-up, repeat CT, complete vaccinations for hepatitis A and B, shoulder x-rays, upper endoscopy and multiple office visits. There was no emergent medical condition noted in the records submitted for review during the dates in dispute. Based on the clinical documentation submitted for review, the services provided between the dates of service in question were not emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 54-year-old male enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees tension headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy 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 the AmnioFix material for treatment of the enrollees necrotizing fasciitis. Findings:  2/3 of the physician reviewers found that Amnion chorion products are well established treatments to promote wound healing. According to a study by colleagues, the results from both the in vitro and in vivo experiments established that dehydrated human amnion/chorion tissue allografts retain their biological activities related to wound healing, including the potential to positively affect four distinct and pivotal physiological processes involved in wound healing including cell proliferation, inflammation, metalloproteinase activity and recruitment of progenitor cells. According to Tenenhaus, amniotic membrane has long been recognized to possess unique properties favorable for healing. All told, the AmnioFix material was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in family practice 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in infectious 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.Physician reviewer number three 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: Overturned

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. Moreover, the AAN guidelines note that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. California State Assembly Bill 88 (Mental Health Parity Law) requires coverage for nine diagnoses for severe mental illnesses and serious emotional disturbances in children including autism. Speech therapy is a well-accepted treatment modality for children with autism. In this case, the patient has a diagnosis of autism with documentation of associated speech delay.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for UroLift procedure. Findings:  Two of the three physician reviewers found that there is support for the requested services in this clinical setting. The UroLift has been accepted by the American Urological Association as a standard treatment for benign prostatic hyperplasia. The procedure offers advantages over transurethral resection of the prostate, such as minimal anesthesia, minimal blood loss, less chance of incontinence and minimal use of a catheter in the postoperative period. Thus, the requested UroLift procedure is likely to be more effective than other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in urology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Anser IFX testing for the treatment of Crohns Disease.Findings:  Three physician reviewers found that the Anser IFX test was ordered to direct the use of infliximab in this patient with Crohns disease.  However, the use of Anser IFX to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Based on the clinical literature, the Anser IFX testing performed was not likely to be more beneficial for evaluation of the patients medical condition than standard management.Final Result: Three 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: Reviewers 1, 2, and 3 are board certified 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: Overturned

The parent of a 6-year-old male enrollee has requested inpatient psychiatric services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that re-admittance to an inpatient psychiatric level of care was medically appropriate as it was reasonable to expect that the services would improve the patients condition and prevent a more serious illness. The initial services consisted of active treatment that was delivered with an individual treatment plan.  However, based upon the records provided, the patient maximized the benefit of this treatment setting by the date indicated.  As of that date, the patient was sleeping well without a sedative.  He was euthymic.  He was not suicidal.  He was stable on medication and the regimen was being modified.  The treatment team determined that the tantrums are largely behavioral and that the appropriate treatment is behavioral and needs to occur at home. Considering the patients status, continued inpatient level of care was no longer medically necessary and transition to a less restrictive setting would have been appropriate.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The ambulance services provided on the day of dispute were necessary for treatment of an emergency medical condition. In this case, the patient experienced the sudden onset of hives and shortness of breath. The paramedics documented tachycardia with visible hives on the anterior neck. The paramedics treated the patient with a parenteral antihistamine. Based on the clinical documentation submitted for review, the patients symptoms support an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue.  Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer number one 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: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested plasmapheresis for treatment of his myasthenia gravis.  Findings:  The physician reviewer found that this patient has generalized MG that is currently in remission. He has had no significant symptoms since at least 2009 and all of his neurologic examinations are normal or near normal. He may have become psychologically dependent on his every six month PLEX treatment. The patient indicates that he has double vision and breathing issues, but has not reportedly followed up with his primary care physician or a neurologist to determine if there are any objective findings. PLEX is commonly used in MG, specifically in patients who are in myasthenic crisis or who have significant weakness or bulbar symptoms while on standard treatment. However, diplopia alone is not an indication for PLEX. Further, there is no evidence that withholding PLEX will lead to worsening symptoms. The patient should only be treated with PLEX if he develops clear myasthenic symptoms, which are not present at this time. Given the absence of myasthenic crisis or significant worsening of myasthenic symptoms, the requested plasmapheresis is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested the medication Lamisil for the treatment of the enrollees onychomycosis. Findings:  The physician reviewer found that the submitted medical records confirms that this patient has a diagnosis of fungal infection with his culture report demonstrating the presence of trichophyton rubrum. The patient has experienced secondary infection (cellulitis) as a result of the onychomycosis which required treatment with antibiotics. Thus, systemic treatment with Lamisil is medically indicated in light of the cellulitis. Furthermore, the patient reports the infected toenails are painful which is likely to affect function. All told, the patient is an appropriate candidate for treatment with Lamisil and the medication should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has diagnoses that include polyneuropathy, morbid obesity, spina bifida and paresthesia of skin. She uses a wheelchair for ambulation but has limited ambulation inside her home. The patient reported edema in both lower legs. The physical examination revealed edema in the lower extremities. No skin lesions or abnormalities were documented in the physical examination. The patient has requested coverage for compression stockings. The Health Plan denied the request and reported compression stockings were not medically necessary for the treatment of this patient. At issue in this case is whether compression stockings are medically necessary for the treatment of this patients medical condition. This patients records do not include a clinical diagnosis or physical examination findings that support a diagnosis of venous insufficiency or lymphedema. In addition, there is no diagnosis of deep vein thrombosis (DVT), no documented concern for DVT, and there was no evaluation ordered for DVT. Compression stockings are appropriate to manage edema due to venous insufficiency, lymphedema and DVT. However, compression stockings are not indicated to manage edema as a symptom without identifying the cause. Thus, compression stockings are not medically necessary to treat this patients medical condition.Final Result: The reviewer determined that the requested service 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 family practice 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 41-year-old male enrollee has requested for lumbar artificial disc replacement for treatment of his lower back pain. Findings:  Three physician reviewers found that artificial disc replacement presents a novel surgical approach to the treatment of degenerative disc related low back pain, interbody fusion remains the standard of care surgical procedure for this condition. At this time, there is insufficient peer-reviewed evidence that artificial disc replacement has an equal or superior long term efficacy and safety profile to traditional interbody fusion surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested canaloplasty for treatment of his advanced pigmentary glaucoma. Findings:  Two physician reviewers found that the requested services are likely to be more effective than other treatment options. In patients on maximal medical therapy for glaucoma, if visual field and optic nerve findings are progressing, surgical modalities are considered.  Trabeculectomy is an invasive surgery which can significantly lower intraocular pressure in patients when maximal therapy is ineffective.  However, there are many complications and failures associated with these procedures.  Canaloplasty is an effective and less invasive modality.  The study by Brusini noted that canaloplasty provides very promising surgical outcomes.  In light of the quick progression of visual field and optic nerve changes in this patient, and the lack of success with maximal medical therapy, canaloplasty would be an effective and low risk way to control intraocular pressure.  Therefore, the requested canaloplasty is likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested acute hospitalization admission for treatment of her abdominal pain.  Findings:  The physician reviewer found that the submitted medical records do not support the medical necessity of the requested services.  This patient has severe recurrent abdominal pain which remains idiopathic.  She has had a very comprehensive evaluation.  Although it is possible the patient has diabetic gastroparesis, the abdominal pain symptoms appear to be too severe and she has not responded to Reglan.  However, the submitted documentation does not demonstrate the need for acute hospitalization at this time.  Inpatient care may be necessary if the patient has intractable vomiting or is unable to maintain hydration.  All told, the requested acute hospitalization admission is not medically indicated for the treatment of this patient.