Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294). Accelerated partial breast irradiation (APBI) may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy (IORT). IORT to perform APBI is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria per current National Comprehensive Cancer Network (NCCN) guidelines. Researchers reported that at four-year follow-up, local control rates between IORT and external beam whole breast radiotherapy were largely equivalent. A study concluded that, Important radiation-related quality of life parameters after IORT were superior to external beam radiation therapy. Per the authors, toxicity may also be slightly improved with IORT. This patient meets ABPI criteria set by the American Society of Breast Surgeons (ASBS), given her age and the presence of a tumor measuring less than 3 cm. All told, the requested IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) is 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 IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) is 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 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. This patient with cervical radiculopathy has experienced persistent neck pain and other symptoms including headaches and dizziness. She reported some symptomatic improvement and range of motion improvement with formal physical therapy. There is a paucity of high-quality evidence informing treatment for cervical radiculopathy, including the efficacy of exercise and physical therapy interventions such as manual therapy and traction. Current treatment guidelines related to the management of cervical radiculopathy are lacking, while higher quality studies are underway. There is a lack of high grade, evidence-based support for prolonged formal physical therapy in this clinical setting. Treatment should include services in the formal therapy setting until transition to an independent program can be made. However, there is a lack of an indication in the available records that this patient has impairments that preclude full transition to an independent program with exercises and modalities that can be applied independently for further improvement in range of motion and symptomatic management. There is no reasonable expectation that her clinical course or outcomes with further formal therapy would be marginally improved over an independent program. The patients documented exercises in the formal therapy setting can be performed independently or substituted with independent exercise. For palliation, the patient can use topical heat, self-massage techniques, and independently applied electrical stimulation pads. All told, the requested physical therapy is 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Laparoscopic Sleeve Gastrectomy.Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity (Mechanick, J., et al.). Mechanick and associates have developed updated clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. These guidelines recommend that all patients should undergo a psychosocial-behavioral evaluation as well as an appropriate nutritional evaluation before any bariatric surgical procedure. In this case, the patient has been documented to have both severe obesity with a BMI of 35 kg/m2 and the co-morbid condition of hypertension. The patient is noted to have been obese and struggling with weight since childhood, and she has a long-term history of prior weight loss efforts that have not been successful in maintaining any significant weight loss. Records document that the patient has also successfully completed a standard multidisciplinary evaluation. Under these circumstances, the requested Laparoscopic Sleeve Gastrectomy is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for this patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. A study notes that rifaximin treatment appears effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). Another study found that rifaximin effectively normalized the glucose hydrogen breath test (GHBT) and reduced the symptoms of irritable bowel syndrome (IBS) by possibly counteracting SIBO. An additional study notes that rifaximin plus neomycin is superior to neomycin alone in improving multiple constipation-predominant IBS symptoms. In this case, the patient has diagnoses of IBS with constipation and SIBO. While antibiotics such as fluoroquinolones may address bacterial overgrowth, they would not be expected to improve irritable bowel syndrome. Given the current medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg tablets is medically necessary for the 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 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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan. Findings:  The physician reviewer found that The records provided for review document that this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable. Based on the available records, there is no current indication for a PET scan. The National Comprehensive Cancer Network (NCCN) guidelines do not support routine use of PET scans for the surveillance of patients with triple negative breast cancer. Current data have reported that PET imaging has high false-negative rates in the detection of lesions that are smaller than 1 cm or are low grade. For these reasons, the requested PET scan is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral upper lid blepharoplasties. Findings:  The physician reviewer found that Hahn and colleagues note that upper lid blepharoplasty is a common procedure that can be performed safely and reliably. In this case, a physical examination and photographs show that the patient has significant dermatochalasis. The patient reports functional deficits related to her decreased vision due to her eyelids. In this clinical setting, the requested services are medically indicated. Therefore, bilateral upper lid blepharoplasties 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 ophthalmology 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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rinvoq (upadacitinib) extended 24-hour release 15 mg. Findings:  The physician reviewer found that In this case, the patient has rheumatoid arthritis and reported good response to Rinvoq. Given that the documentation shows that the patient has tried and failed multiple TNF inhibitors, a trial of another TNF inhibitor when she has had good response to another class of medications is not medically indicated. Therefore, Rinvoq (upadacitinib) extended 24-hour release 15 mg is medically necessary for the 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 internal medicine with sub-specialty certification in rheumatology 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.
Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for brand medication, Norditropin FlexPro. The U.S. Food and Drug Administration (FDA) has approved GH therapy for patients with idiopathic short stature. This patients growth chart and clinical records support that this patient initially met FDA approved criteria for treatment with GH therapy due to idiopathic short stature with height z-score below -2.25 SDs from about age seven to age nine, despite treatment with somatotropin during some of this timeframe. Absent true puberty, this patients height z-score eventually improved significantly into the normal range while receiving somatotropin therapy, a clinical response displayed by a minority of prepubertal patients with idiopathic short stature. Her recent predicted adult height remains more than 2 SDs below the mean for North American women. Her growth pattern and bone ages have been consistent with her familial pattern of growth and development and consistent with both benign premature adrenarche and familial idiopathic short stature. Somatotropin therapy is indicated to help the patient attain a final adult height z-score above -2 SDs for North American women. However, this patients records lack documentation to meet the criteria for treatment with GH therapy. Specifically, there is no record of karyotype testing to exclude mosaic Turner syndrome, or brain MRI with and without gadolinium contrast obtained either before or after initiation of somatotropin. In the absence of this data, the requested Brand medication, Norditropin FlexPro is not medically necessary for 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 board certified in pediatrics with subspecialty certification in pediatric endocrinology 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.
Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to substance abuse, including a recent overdose requiring hospitalization. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with parents and social isolation due to substance use. The patient demonstrated recent gains or stabilization in functioning while participating in treatment in a structured, protected, and/or enriched service. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse, hallucinations, and a history of pancreatitis. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to the recent death of his grandmother, and his fathers illness and homelessness. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, as he overdosed while participating in a partial hospitalization program (PHP), and his symptoms of depression, anxiety, and cravings continued in residential treatment.With regard to treatment acceptance and engagement, the records support a score of 2. The patient was motived and participated in treatment.Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored residence-based services, due to the serious risk of harm score of 4. This is consistent with the RTC level of care. Therefore, RTC services are 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 overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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.
The patient has requested authorization and coverage for continued hospitalization until her course of antibiotics is complete for her infection, and her heart rate is stabilized. The records provided for review document a history of glioblastoma multiforme, stroke, seizures, and sinus tachycardia. The patient has been diagnosed with a urinary tract infection (UTI) and she is currently on antibiotics. There is a lack of clinical indication for the patient to remain admitted to the hospital in order to complete her antibiotic dosing. Such medications can be safely administered in a long-term care setting such a skilled nursing facility or another long-term care facility. Moreover, prolonged hospitalization increases this immunocompromised patients risk to other infections. As such, an infection such as a UTI is treated without inpatient care in an outpatient setting when possible. For these reasons, the requested continued hospitalization until her course of antibiotics is complete for her infection and her heart rate is stabilized is not medically necessary for treatment of this patient.
Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for speech therapy services. The submitted documentation supports the medical necessity of the requested services. Speech therapy is standard of care for children with autism spectrum disorder. Hyman and colleagues stated, All children with autism spectrum disorder (ASD) should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with ASD. Researchers noted the importance of early intervention for children with autism spectrum disorder. Studies concluded that behavioral interventions were evidence based to induce speech among individuals with developmental disabilities. Scientists described treatment for autism spectrum disorder involving intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. In this case, although the patients progress is slow, he continues to make progress. His providers recommend that speech therapy be continued. Therefore, speech therapy services 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 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.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Wide local excision of melanoma in situ.  Per Health and Safety Code section 1345(h), health plans are required to cover urgent care services. Per that same provision, urgent care services are defined as, services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury. The records provided for review document that this patient presented to his provider with a diagnosis of melanoma in situ on the cheek, which required excision. Based on the definition of urgent care services, the patients melanoma did not require urgent excision on the date of service. The American Academy of Dermatology (AAD) guidelines on the management of melanoma recommend definitive excision within two months of diagnosis. Moreover, current data suggest that there is a paucity of evidence to suggest that a shorter timeline for removal of the tumor changes long-term patient health outcomes. Based on these findings, the procedure could have been performed within the two-month timeframe without urgent excision on the date of service. A wide local excision by a plastic surgeon or dermatologist was reasonable. There was no reasonable expectation of deterioration in the patients health to support an urgent indication for the procedure. Therefore, the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. 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.
An enrollee has requested authorization and coverage for laparoscopic radiofrequency ablation of fibroids. This patient has heavy bleeding, pelvic pain, and bulk symptoms. Ultrasound demonstrated that the patients fibroids are intramural and less than 6 cm. Standard options for treatment include hysterectomy, myomectomy, and uterine artery embolization. Radiofrequency ablation procedure is a less invasive alternative treatment for myomas of appropriate size and location. Researchers found that radiofrequency ablation of uterine fibroids reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates. Based on the peer-reviewed medical literature, the requested laparoscopic radiofrequency ablation of fibroids is 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 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 obstetrics and gynecology 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.