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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for urgent care services provided on 8/15/16. Findings:  The physician reviewer found that the patient reported low back pain with movement. The patient was evaluated in urgent care without any diagnostic testing. A screening history was performed including vital signs, but there was no evidence that a physical exam was performed. The patient was felt to have musculoskeletal back pain. The patient was discharged home with recommendations for over-the-counter analgesics, stretching, and heating pad. The patients parent is requesting reimbursement for the urgent care services provided on 8/15/16. 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 services provided on 8/15/16 were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient presented with low back pain with movement. According to Nigrovic Although back pain may be a sign of a more concerning problem, especially in children younger than 10 years, most episodes of back pain in children are not serious and resolve without treatment. In addition, the patient had normal vital signs and no diagnostic testing was performed. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for platelet-rich plasma injection for temporomandibular joint disorder. The enrollee has a history of teeth grinding and temporomandibular joint disorder. She complained of jaw pain, neck pain, and ringing in her ears. Findings: the physician reviewer found that  She has been treated with ear insufflation and a transcutaneous electrical nerve stimulation (TENS) unit. She underwent a sleep study for snoring and non-refreshing sleep. The study showed a low oxygen saturation of 89% during sleep and she was given a retainer. She also has been given fixed orthotics for her mouth, different mouth guards, Invisalign, as well as chiropractic treatment. She continues to have tinnitus, as well as pain in the ears, teeth, neck, cheeks, shoulder, and arms. She has a deviation of her right jaw at maximum opening and crepitus on the right. Due to failure of resolution of symptoms, ultimately she was referred to a provider who recommended platelet rich plasma injections into the temporomandibular joint. The medical literature indicates attempts are being made to determine whether platelet rich plasma injections are helpful in mitigating temporomandibular joint pain and discomfort. Although this treatment shows promise, it was found the studies performed to date were of low quality evidence with equivocal results, with many studies showing no better outcome than standard therapy, and therefore they could not recommend this treatment at this time.  Other studies were more direct and felt that PRP should not be first line treatment. There is no definitive nationally recognized standard for PRP or a high quality evidence study to support PRP over other modality treatment. Evidence of its efficacy has been highly variable depending on the specific indication.  Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in oral and maxillofacial surgery, another is board certified in pain management, and the third is board certified in otolaryngology and facial plastic reconstructive 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a highchair/activity chair. Findings: In this case, given that a DME evaluation has recommended a commode chair and a collapsible adaptive tilt-in-space wheelchair that could serve the functions of an activity chair, the requested equipment would be duplicative. Therefore, a highchair/activity chair is not medically necessary to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment 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 neurology with special qualification in child neurology 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 weekly cognitive behavioral therapy (CBT), weekly eye movement desensitization and reprocessing (EMDR), and 24 sessions of weekly vision therapy. Based on the available documentation, the request for weekly CBT is medically necessary for treatment of this patient. The patients symptoms include anxiety, panic, binocular vision dysfunction, and insomnia. Weekly appointments with a therapist for CBT is indicated to address this patients current symptomatology. Although an intensive outpatient program (IOP) would allow visits that are more frequent with a psychiatrist and therapist, long-term continuity with a therapist and psychiatrist is central for this patients recovery. However, the requested EMDR therapy is not medically necessary for this patient. EMDR is supported as effective for the treatment of patients with post-traumatic stress disorder (PTSD). The records provided for review do not document a history of PTSD or that PTSD is central to the patients current symptomatology. Moreover, vision therapy is not appropriate for treatment of this patients symptoms. There is a paucity of support in the peer-reviewed medical literature to support a role for vision therapy in this clinical setting. The requested 24 sessions of vision therapy is not medically necessary for treatment of this patient. Given these findings, weekly CBT is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested weekly CBT is 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 63-year-old woman with a documented long-standing history of back and shoulder pain that has been unresponsive to physical therapy and chiropractic intervention. The submitted photographs show bra strap grooving and large, pendulous breasts. The planned breast reduction exceeds the 22nd percentile on the Schnur table. The Health Plan has denied authorization for the proposed procedure on the basis that it is not medically necessary for treatment of the patients condition.Review of the submitted clinical evidence demonstrates breast reduction surgery is medically necessary for this patient. She has breast hypertrophy, and her complaints of shoulder, neck, and back pain and bra strap grooving are typical of symptomatic macromastia. The submitted photographs confirm pendulous breasts with significant residual volume despite her massive weight loss. Her symptoms have not improved with chiropractic treatments and physical therapy, which is not surprising since symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. The value of breast reduction in improving or correcting symptoms of macromastia is well documented in peer-reviewed scientific studies. As noted by Kerrigan, et al., weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.  Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested authorization and coverage for accelerated partial breast irradiation (APBI), also known as brachytherapy for treatment of the enrollees ductal carcinoma in situ (DCIS). Findings:  The physician reviewer found that partial breast radiation is somewhat controversial, and many practitioners do not consider it standard therapy outside of a clinical trial. Given the abundance of Phase I-II data, and at least four published randomized studies, partial breast irradiation is becoming an accepted standard. However,  final results of the NSABP B-39/RTOG 0413 Phase III study for lower risk early stage breast cancer have not yet been concluded.  Because of this, experts in the field recently published an American Society for Radiation Oncology (ASTRO) consensus statement (Smith, et al.) regarding accelerate partial breast irradiation (APBI) therapy, acknowledging that it is becoming standard practice in the community, despite the paucity of Phase III data.   Patients with pure DCIS or age 50-59 fall within the ASTRO consensus statements cautionary group in which the treatment of women with any of those criteria should invoke caution and concern when considering APBI.  So this patient, whose age is less than 60 at the time of radiation and who has what appears to be DCIS, would fall into the cautionary group.  Also, women with multifocal disease, which may be the case for this patient as she had two lesions seen on breast MRI, fall into the cautionary group. Additional factors for cautionary use of APBI include estrogen receptor negative, tumor size 2.1-3 cm, lobular cancer, EIC?, close margins, and limited/focal LVSI. More aggressive pathologic features fell into the unsuitable category for APBI. The National Comprehensive Cancer Network (NCCN) guidelines are also in accordance with the ASTRO guidelines. Additionally, the data available in the peer reviewed medical literature demonstrates there is currently a paucity of long term data examining the safety and efficacy of APBI. In this patients case, the long term efficacy of APBI has not been proven in the peer reviewed medical literature and should be offered to patients with DCIS only in the setting of a prospective study. All told, the requested APBI is not medically necessary for treatment of the patients DCIS. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has tried and failed therapy using topical steroids. However, there is no documentation of treatment failure, intolerance, or contraindication to the use of the preferred first-line agents, such as methotrexate, acitretin, Enbrel or Humira. The fear of immunosuppression does not represent a true contraindication to the use of these medications.  There are preferred alternative therapies available for this patient.  All told, Otezla is not medically necessary for the treatment of this patient. 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of the patients hepatitis C infection. 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 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 53-year-old female enrollee has requested electron beam computerized tomography (EBCT) coronary artery calcium (CAC) scoring for an evaluation of her potential coronary artery disease (CAD). Findings:  Three physician reviewers found that EBCT calcium scoring has been advocated for many years by some, for the assessment of cardiovascular risk. However, its role in the evaluation of asymptomatic or low-risk patients such as this patient, has not been established. According to two recent consensus reports published in the Journal of the American College of Cardiology, EBCT CAC scoring is not deemed appropriate for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient been diagnosed with bilateral knee degenerative joint disease with underlying advanced patellofemoral chondromalacia. The patient received Monovisc injections to bilateral knees in August 2019. The patient reported slow improvement due to prior viscosupplementation injections with less pain and sensitivity. The patient was noted to have had improvement due to prior viscosupplementation injections. The patient reported knee pain, left greater than right. The provider noted x-rays demonstrated some joint space narrowing and bony sclerosis. The patient has requested authorization and coverage for viscosupplementation (hyaluronan) injections in both knees. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether viscosupplementation (hyaluronan) injections in both knees is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections. The alternative is bilateral total knee arthroplasties. The medical evidence supports the requested service in this clinical setting. Therefore, viscosupplementation (hyaluronan) injections in both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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

The patient is a 20-year-old female with symptomatic breast hypertrophy documented by her plastic surgeon. The patients plastic surgeon has recommended breast reduction surgery. The Health Plan indicates breast reduction surgery is not medically necessary based upon the amount of breast tissue to be removed.The appropriate and medically necessary procedure for this patient is breast reduction. According to the American Society of Plastic Surgeons guidelines, the weight of the removed breast tissue does not determine whether the procedure is medically necessary. In this case, the plastic surgeon examining the patient noted symptoms of back, neck, and shoulder pain related to large pendulous breasts for which the patient wears two bras simultaneously for comfort in activities. In addition, the submitted photograph supports the findings of the plastic surgeon. Given these findings, breast reduction surgery is medically indicated.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The partents of a 16-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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 upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx melanoma gene assay for evaluation of the enrollees melanoma of the left upper arm.Findings:  Three physician reviewers found that Decision Dx examines has shown some accuracy in thin melanomas like in this case. However, what to do with the results of the test are indeterminate at this point. The treatment of this patient would not change based on the results of the exam. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature to support its use in the care of patients with thin melanomas to effect health outcomes. Final Result: Three physician reviewers determined that the testing 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: All three physician reviewers are board certified in dermatology 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 patient has requested authorization and coverage for Ilumya. Findings: Psoriasis is a chronic relapsing and remitting disorder of the skin and immune system that can be treated with a multitude of safe and effective treatment modalities including biologic medications. Although the advent of biologic therapies has changed the treatment landscape, disease modifying anti-rheumatic drugs (DMARDs) like methotrexate and acitretin are still widely used, either as monotherapy or in combination with biologic medications. According to the most recent guidelines of care from the American Academy of Dermatology, methotrexate is recommended for the treatment of moderate to severe psoriasis in adults but is less effective than adalimumab and infliximab for cutaneous psoriasis. Cyclosporine is used in psoriasis for its rapid onset of action but usually as a bridge to long-term therapy due to its side effect profile. This patients records do not document adequate trials and failures or contraindications to standard of care therapies to support an indication with Ilumya. Moreover, the Health Plans formulary includes Humira, which is biologic medication that has been shown to be safe and effective for the treatment for this patients medical condition. For these reasons, the requested Ilumya is not medically necessary for treatment of this patient. 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 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.