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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for U.S. Food and Drug Administration (FDA) approved noninvasive laminotomy/laminectomy, foraminotomy/foraminectomy, and discectomy (LFD) and disc replacement. Findings:  The physician reviewer found that Srinivas and colleagues noted that alleviation of clinically significant low back pain after lumbar decompression surgery for neurogenic claudication was observed at three, 12, and 24 months in the majority of patients treated. Held and colleagues concluded that there is strong evidence that surgical treatment is superior to nonoperative treatment for elderly patients with degenerative lumbar spinal stenosis. Wang and colleagues reported that concomitant degenerative spondylolisthesis does not influence the outcome of decompression alone in degenerative lumbar spinal stenosis, especially when a minimally invasive procedure was performed, and patients did not have predominant symptoms of mechanical back pain. The presence of degenerative spondylolisthesis is not considered an indication for surgery in degenerative lumbar spinal stenosis. The FDA approval for the ProDisc-L total disc replacement states that this device is indicated for patients with degenerative disc disease at one level in the lumbar spine from L3 to S1 with no more than grade 1 spondylolisthesis at the involved level and symptoms that have persisted despite at least six months of non-surgical treatment (Zigler and Delamarter). The records provided for review document that this patient is being treated for lumbosacral disc degeneration and lumbar spondylosis. Progress notes indicate a greater than 20-year history of low back pain. The pain is noted to be mainly axial, localizing to the waist with occasional radiation into the buttocks and hips, and left thigh and heel. Detailed documentation is not evident regarding specific objective findings corroborating nerve root compression to support the requested decompression procedures. The patients magnetic resonance imaging (MRI) revealed multilevel significant degenerative disc disease and stenosis. In this clinical setting of multiple possible significant pain generators, there is a lack of a specific indication for disc replacement. Therefore, the requested FDA approved noninvasive LFD and disc replacement are not medically necessary for 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 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 parent of a 17-year-old male enrollee has requested at least 100-120 days of intensive residential traumatic brain injury rehabilitation for treatment of the enrollees traumatic brain injury.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Per the medical records, this patient had a traumatic brain injury and continues to have symptoms consistent with this injury.  The medical literature supports intensive residential traumatic brain injury rehabilitation for the treatment of this patient.  The requested services are standard of care in this setting.  All told, the requested 100-120 days of intensive residential traumatic brain injury rehabilitation are medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 32-year-old female with degenerative disc disease with involvement at L5-S1. The patient has undergone conservative treatment without sustained relief. She is requesting authorization for artificial disc replacement at L5-S1. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term efficacy. The best-published results reveal outcomes equivalent to fusion. However, the majority of studies show a failure rate of 35%. Furthermore, the long-term safety profile is unknown. In addition, there are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 32-year-old female with degenerative disc disease. She has had intermittent pain since she was involved in an automobile accident. She is status post nucleoplasty with increased pain. Her provider believes the L5-S1 disc is responsible for the patients pain and is recommending artificial disc replacement with the Charite disc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 32-year-old female with degenerative disc disease. She is seeking authorization for artificial disc replacement utilizing the Charite disc. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee has requested physical therapy for treatment of her status post fracture of shaft of tibia.  Findings:  The physician reviewer found that the submitted documentation indicates that the patient partially achieved goals, but a home exercise program was recommended in preparation for additional skilled rehabilitation. The medical notes indicate that the patient had plateaued functionally and had achieved her pre-fracture level of function. Further gains were not expected. In order for skilled physical therapy to be considered medically necessary, it should be reasonably expected that significant functional gains will be achieved. This patient has received training in a home exercise program. All told, the requested physical therapy is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an Afirma gene expression classifier for evaluation of the enrollee, who was diagnosed with follicular thyroid lesion. Findings:  Three physician reviewers found that the patient presented with thyroid nodules, sized at 1.5 and 1.3 cm in diameter.  The patient has past history of left breast ductal carcinoma. Thyroid biopsy was performed in two nodules.  The cytopathology diagnosis was consistent with atypia of undetermined significance (AUS) in both nodules. The specimen was then sent to genetic expression classifier (GEC). The Afirma GEC result was suspicious. The patient requested reimbursement for Afirma gene expression classifier test. Per the Health Plan, the services at issue were investigational for evaluation of the patients medical condition. The cytopathology of both nodules was consistent with atypia of undetermined significance. The 2015 American Thyroid Association's guidelines state that for nodules with AUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat fine needle aspiration or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this patients case, the results were suspicious in both nodules. The fact that two nodules were suspicious, increase the certainty that this patient may have a multifocal thyroid cancer. The result from the gene testing was helpful to direct subsequent management, in this case, surgery. Proceeding with genetic testing was appropriate and in line with current specialty standards. Therefore, the Afirma gene expression classifier was likely to be more efficacious than other methods of evaluating of this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 bilateral hyaluronan (Gel-Syn) injections. Findings:  The physician reviewer found that Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited.  In this case, the patient has a history of relief from prior injections of both knees lasting up to six months. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral hyaluronan (Gel-Syn) injections are medically necessary for the 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: Urgent Care
Decision: Upheld

A 51-year-old female enrollee has requested emergency services for the treatment of her medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent  medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This case does not meet the prudent layperson criteria for emergent care. The patient did not have severe pain or visual impairment. The symptoms initially presented about two days prior to her presentation in the ED. A prudent layperson with average knowledge of medicine would not believe he or she were experiencing an emergent medical condition requiring immediate care based upon this patients symptoms. The patient could have waited an hour or two and presented to her primary care providers office or to an Urgent Care Center for diagnosis and treatment rather than going to the ED.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female with Bipolar Disorder, Type II, who is currently treated with Wellbutrin, Xanax, and Ambien CR.  The Ambien was prescribed due to difficulty with sleep continuity and the patient found this medication more useful than the previously prescribed Rozerem.  A review of the patients medication log for the past two years shows her to have received other antidepressants such as Cymbalta and Lexapro, either alone or in combination with Wellbutrin. Topamax was also prescribed, presumably as a mood stabilizer.  The patients sleep reportedly did not improve with medications such as Seroquel due to unspecified side effects. In January 2006 the patients provider documented that the patient was sleeping better with Ambien CR, 25mg, but that she still has some ups and downs. The patient is now requesting authorization for Ambien CR at a dosage of 25mg nightly.  The Health Plan issued a denial based upon a determination that the requested medication dosage is not medically necessary.The approach taken in treating the patients Bipolar Disorder, Type II, is unique in that conventional mood stabilizers have only been prescribed on a limited basis and the patient is apparently maintained on concurrently prescribed antidepressants. A sleep continuity disturbance could certainly be understood in that context.  Treatment with Ambien or other soporific agents is not the typical treatment approach for discontinuity of sleep as a component of a Bipolar Disorder. Therefore, I have determined the requested medication dosage 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 authorization and coverage for Orthovisc injection series in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, prior viscosupplementation was beneficial. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, Orthovisc injection series in both knees are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 Nurtec 75 mg tablets. The records provided for review document that this patient has a history of migraines. The provider reports that the patients symptoms that have not substantially improved despite treatment with nortriptyline, Topamax, Riboflavin, Propranolol, and Maxalt. The patients provider has recommended treatment with rimegepant (Nurtec). The U.S. Food and Drug Administration (FDA) has approved Nurtec for the treatment of patients with migraine. Nurtec is in the calcitonin gene-related peptide receptor (CGRP) antagonist family of medications that has been demonstrated in clinical trials to be safe and effective in the management of patients with migraine. Researchers reported on a double-blind randomized controlled clinical trial comparing Nurtec to placebo. The authors concluded that, In the acute treatment of migraine, a single 75 mg dose of rimegepant [Nurtec] in an orally disintegrating tablet formulation was more effective than placebo. Given these findings, the requested Nurtec 75 mg tablets are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in vascular 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for subcutaneous implantable cardioverter defibrillator (ICD). Based on the records provided for review, the patient has hypertrophic cardiomyopathy. The patients records document an increased risk of sudden death as evidenced by sudden death in his brother and non-sustained ventricular tachycardia (NSVT). In this circumstance, placement of a cardioverter defibrillator is appropriate. However, there is no documented contraindication to a standard implantable cardioverter defibrillator using a transvenous ventricular lead. In addition, optimal patient selection criteria and long-term complications with a subcutaneous leadless defibrillator have not been established. Further, a subcutaneous leadless defibrillator does not have the capability of providing back up cardiac pacing in cases of bradycardia or anti-tachycardia pacing as a first tier approach for treating spontaneous ventricular tachycardia. By contrast, a standard transvenous defibrillator has these capabilities. All told, the requested subcutaneous implantable cardioverter defibrillator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three of the three 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for urgent care services for treatment of an emergency medical condition.Findings:  The physician reviewer found that the 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 urgent care services 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 a sore throat and normal vital signs. There is no documentation supporting the patient was experiencing an acute onset of symptoms. 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: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested for an osteotomy consultation to reduce nose width for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the most reasonable option is for the patients optometrist to attempt to fit the patient with a size 22 or 23 frame rather than to pursue surgical intervention, which is invasive and carries risk. The medical literature does not document any cases of rhinoplasty to facilitate eyeglass use.