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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.Findings: The documentation provided does not support the services at issue in this clinical setting. On 6/8/18, the patient requested an emergent appointment with her therapist and psychiatrist. The type of emergency was not noted in the documentation. Per the record, the patient was given an appointment with her psychiatrist on 6/28/18 and an appointment with her therapist on 7/11/18. The patient felt that this was too long for treatment. The patient did not endorse suicidal or homicidal ideation. The provider discussed treatment options available with patient. A two to three week wait to see a psychiatrist for an outpatient visit with access to emergency services is considered standard of care. There is no documentation of the patients current weight, body mass index, or ideal body weight. The patient reported that outpatient care has not helped her condition. Her medical note on 5/16/18 stated that her Behavioral Impairment Index (BHI) has decreased from 98 on 7/26/17 to 68 on 5/16/18. The patients health questionnaire (PHQ-9) score has decreased from 23 on 7/26/17 to 16 on 5/16/18. Based on the records provided, the patient has been making progress in her recovery while participating in outpatient treatment. The patients mother is supportive of the patient. The standard of care for residential treatment for eating disorders is reserved for patients who have an ideal body weight less than 80%. In this patients case there was no documentation stating that the patient had an ideal body weight less than 80%. The patient did not endorse suicidal or homicidal ideation. While the patient continues to require treatment for her borderline personality disorder and eating disorder, treatment can be accomplished in a less restrictive environment. Therefore, residential treatment services are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in eating disorders 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: An enrollee has requested reimbursement for Flexitouch programmable pneumatic compression pump. In this patients case, there is a lack of indication for a pneumatic compression pump. The patient was noted to have edema after a knee injury that continued despite mild compression stocking use. However, the patient reported that only her foot was swollen after sleeping, which suggests that the patients edema improved with elevation. Blumberg and colleagues reported favorably on the use of pneumatic compression on 100 patients in all treatment groups with use of the Flexitouch system. The authors cautioned that their study was limited in the lack of standardization of all aspects of lymphedema care and lack of a control group, making it difficult to draw more than general conclusions about the benefit of pneumatic compression. Intermittent pneumatic compression is accepted medical treatment for lymphedema when used in conjunction with limb compression and oftentimes manual lymphatic drainage. However, studies have not demonstrated long-term improved patient health outcomes with use of the Flexitouch system as compared to other sequential compression devices in this clinical setting. For these reasons, the Flexitouch programmable pneumatic compression pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Flexitouch programmable pneumatic compression pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was 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 reviewer 1 is board certified in plastic surgery and is actively practicing. Physician reviewer 2 is board certified in surgery with subspecialty certification in general vascular surgery and is actively practicing. Physician reviewer 3 is board certified in plastic surgery and is 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 genetic testing (Lineagen pharmacogenomic panel). Tantisira and colleagues noted that, Pharmacogenetic testing is available in some areas in conjunction with certain drug classes, and may enable physicians to understand why patients respond differently to various drugs and to make better decisions about therapy. However, the goal of individualized therapy based upon pharmacogenetic testing has yet to be realized. The pharmacogenomic testing is not the standard of care, and it has not been proven to be effective for the patients condition. Given these findings, the genetic testing (Lineagen pharmacogenomic panel) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing (Lineagen pharmacogenomic panel) 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 genetic testing (Lineagen pharmacogenomic panel) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in genetics and clinical cytogenetics. Physician reviewer 2 is board certified in pediatrics, neurodevelopmental behavioral pediatrics, and genetics. Physician reviewer 3 is board certified in pediatrics, genetics, and clinical biochemical genetics. The Physician reviewers 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: Urgent Care
Decision: Upheld

A 38-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. 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. This patient had been experiencing a sore throat for three days with subjective fever. He was alert and appeared well. The patients vital signs were normal, and he did not have a fever on presentation. His oxygen saturation was normal, and lungs were clear. The patient was not in any distress. He did not require any treatment in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma injections (CPT 0232T). Findings:  Two of the three physician reviewers found this patient presented with a history of chronic bilateral knee pain. There was imaging evidence of bilateral lateral meniscus tears. Prior hyaluronic acid injections had provided two years of good relief. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure was not submitted. The procedure report documented bilateral knee platelet-rich plasma injections were performed for the diagnoses of bilateral meniscal tears and knee pain. There is an absence of large well-designed clinical studies to support the safety and efficacy of platelet-rich plasma in knee meniscal and cartilage disorders. The use of platelet-rich plasma injections is not supported in this clinical setting. In this patients case, the evidence does not support the use of platelet-rich plasma injections over other conservative treatment options. In sum, platelet-rich plasma injections were not likely to have been more effective than other treatment modalities. Final Result: The reviewers determined that the services at issue were 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 orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the pacemaker provided on 12/15/20. Findings:  The physician reviewer found that  use of an accelerometer based leadless device in a younger patient who requires only single chamber sensing/pacing with complete heart block is a reasonable choice of pacemaker in this clinical setting. In this case, the patient required a permanent pacemaker after surgery with a persistent complete heart block. A Micra accelerometer leadless device was selected given the patients young age and the possible likelihood of multiple revisions and/or lead fracture in a young, active patient over a long lifetime. Additionally, the patients sinus node function was intact, and a single chamber device was all that was necessary for the management of a complete heart block. There was also a small chance that over several weeks/months after healing from surgery the AV block may have resolved, obviating the need for the pacemaker and making a leadless device a more attractive option as well. Therefore, the pacemaker provided on 12/15/20 was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the device at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are 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: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested an ultra lightweight wheelchair for the treatment of her bilateral leg weakness secondary to brain trauma. Findings:  The physician reviewer found that the patient's energy expenditure of ambulation and activities of daily living with bilateral knee-ankle-foot orthoses is extremely high. Fatigue is an expected consequence, and the patient does require a wheelchair in this situation to optimize function. Thus, a wheelchair is medically necessary and indicated to allow continued ambulation and performance of activities of daily living. However, there is a lack of support for the medical necessity of an ultra lightweight wheelchair. The medical notes do not indicate a reason as to why an ultra lightweight wheelchair is needed, as a standard wheelchair would suffice. Thus, while a wheelchair is medically necessary for this patient, the ultra lightweight wheelchair is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy. Findings:  Three physician reviewers found that neuralgia is a type of neuropathic pain. Occipital neuralgia specifically refers to pain or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. In this case, the patient had evidence of occipital neuralgia on examination. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain and act as a diagnostic marker. The medical evidence supports the services at issue in this clinical setting. Therefore, occipital nerve block therapy was likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were 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 neurology 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

A 21-year-old female enrollee has requested acute level of care services for treatment of her depressive disorder.  Findings:  The physician reviewer found that this patient was admitted to an acute inpatient hospitalization unit on the date in question. Her mental status exam was noted to show her to be pleasant and cooperative. She appeared disheveled. Her mood was depressed and her affect congruent, yet in a normal range, stable and not tearful. Her thought process was organized and she did show a thought content of neural-vegetative anxiety and depression with insomnia. At the time of her admission, the patient had suicidal ideation without an active plan and no auditory or visual hallucinations. She has a history of chemical abuse/dependency. Although the patient had been experiencing suicidal thoughts leading up to her admission and during the initial period of her stay, by the said date she was showing less depression and there was no evidence of active suicidal ideation with intent or plan. As of the said timeframe, the patient did not meet medical necessity criteria for continued acute inpatient level of care services, as she was not an imminent danger to herself and/or others, nor was she noted to be severely unstable. The medically necessary level of care during this time was step down to a partial hospitalization program.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bone growth stimulator. According to a cohort study, for treatment of delayed unions and non-unions, low-intensity pulsed ultrasound bone stimulators can provide marginal benefit in patients 60 years of age or older with fracture risk factors (Zura, et al.). The authors reported that patients who used low-intensity pulsed ultrasound experienced a 96% healing rate while the expected averages are approximately 93%. In this case, the patient sustained a left foot injury several months ago and she presents with persistent left foot pain. The records do not indicate whether the patient has failed a trial of standard conservative management to include an adequate trial of immobilization and weightbearing restrictions. The submitted imaging reports do not document a nonhealing fracture of the base of the fourth metatarsal. The imaging report of the left foot MRI and serial radiographic reports demonstrating failed bone union are not included in the submitted medical records to support the diagnosis of delayed union or nonunion. Accordingly, the requested bone growth stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bone growth stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for additional physical therapy (2 times per week for 3 months). While direction and oversight of a postoperative program by a trained physical therapist is clinically appropriate and necessary in the early stages following total joint arthroplasty, current medical literature does not demonstrate a significant benefit of intensive or prolonged standard formal therapy program following total knee arthroplasty. In a systemic review and meta-analysis, researchers report that short-term improvements in physical function and knee range of motion do not clearly differ between outpatient physiotherapy and home-based exercise regimes in patients after primary total knee arthroplasty. Researchers likewise found in a trial of 334 participants that outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. Researchers observed that the burden of comorbidities appeared to better predict outcomes regardless of rehabilitation approach. In this case, there is no expected marginal benefit with respect to clinical course or outcomes from continued formal physical therapy over a conservative management program of exercise and modalities that can be performed at home. Given that the patient has maximized the expected benefit from supervised formal outpatient therapy, the requested services are not medically indicated. Therefore, additional physical therapy (2 times per week for 3 months) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 is requesting Sovaldi for the treatment of his hepatitis C infection. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 the guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 2 regardless of fibrosis stage.  The guidelines do not recommend other regimens for ribavirin-eligible genotype 2 patients.  For these reasons, Sovaldi is medically necessary for the treatment of this 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 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested psychiatric emergency services on an emergent basis. Findings:  The physician reviewer found that at issue in this case is whether the enrollee was experiencing a psychiatric emergency medical condition. A psychiatric emergency medical condition is defined as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or others or (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. In this case, the patient was experiencing a psychiatric emergency medical condition. Upon presentation, the patient had multiple static risk factors and warning signs of immediate danger to self.  Based on the patients presenting symptoms, he was experiencing a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient was experiencing a psychiatric emergency medical condition. Therefore, the Health Plans denial should be 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.