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

A 35-year-old male enrollee has requested anesthesia services for treatment of his ulcerative colitis.  Findings:  The physician reviewer found that based on the records provided, monitored anesthesia care was not medically necessary for this patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts, and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. In addition, colonoscopy may be safely and effectively performed with conscious sedation using a Benzodiazepine alone or with a narcotic in an office based setting and without the need of monitored anesthesia care. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy. At the end of the review, they concluded that, moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Consistent with these findings, the monitored anesthesia care during a sigmoidoscopy was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 13 hours per month of 1:1 applied behavioral analysis (ABA), in addition to the 22 hours of direct 1:1 ABA already approved by the Health Plan. The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that for an individualized ABA treatment plan, a developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress. Researchers report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. In this case, ABA therapy is the most evidence-based treatment for this patients diagnosis of autism. The patients treatment plan includes a wide breadth of outlined goals and how the requested hours will address the essential needs of this patient. Given the scope of treatment and challenging behaviors present, the requested services are medically indicated. In this patients case, 13 hours per month of 1:1 applied behavioral analysis (ABA), in addition to the 22 hours of direct 1:1 ABA already approved by the Health Plan, are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, 13 hours per month of 1:1 applied behavioral analysis (ABA), in addition to the 22 hours of direct 1:1 ABA already approved by the Health Plan, 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 a licensed B.C.B.A, board certified in psychology 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 authorization and coverage for significant wrap around services through a comprehensive transitional program that specializes in young adults with special needs that would allow the enrollee to live at home and that would work with the enrollee on maintaining the enrollee stability while also working on the enrollees independent living skills through a multidisciplinary clinical setting that incorporates vocational, educational, health, independent living, social and recreational goals for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the comprehensive services requested by this patient are safe, appropriate and medically necessary. The treatment components requested in this dispute comprise of core elements of both patient centric and evidence based care that are consistent with current practice standards.  The studies have shown that a multidisciplinary array of clinical interventions will optimize this patients autonomy and reduce a risk for readmission. The patient had been admitted to a residential treatment facility at age 15 but had a recrudescence of symptoms that prompted a second residential admission. The literature supports the recommended multidisciplinary transitional approach to maintain this patients successful transition to the community setting.  Thus, the request for coordinated services in context of a patient specific, multidisciplinary treatment plan is indicated in this clinical setting.  For these reasons, wrap around services through a comprehensive transitional program that specializes in young adults with special needs that would allow the patient to live at home and that would work with the patient on maintaining his stability while also working on his independent living skills through a multidisciplinary clinical setting that incorporates vocational, educational, health, independent living, social and recreational goals are medically necessary for the treatment of this patients behavioral health 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 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: Upheld

A 20-year-old female enrollee has requested residential care services for treatment of her anxiety, post-traumatic stress disorder (PTSD), and polysubstance dependence.  Findings:  The physician reviewer found that the records provided for review indicate this patient was motivated for treatment, and at the time of admission, she was not suicidal or psychotic. The PHP level of care would have provided greater intensity of treatment than the patient had accessed previously and would have been adequate to safely address this patients issues. While there are risks associated with the combination of anxiety disorder and substance abuse, the records do not document that the patient was at imminent risk of harm. In addition, no extenuating circumstances were presented by the patient or the treating providers to suggest that treatment in a less restrictive setting would have interfered with the patient achieving and maintaining sobriety. In sum, the residential care services was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male has requested gastric bypass surgery for treatment of his morbid obesity.  Findings:  The physician reviewer found that the patient does not meet the weight loss surgery guidelines set forth by the National Institutes of Health (NIH) consensus meeting. The basis for the NIH guidelines is a collective risk evaluation. In this patients case, at a BMI of 34, even with his comorbidities, the operative risks outweigh the potential benefits of the surgery. The patient should make further attempts at conservative weight loss and behavior modification prior to considering surgery.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested occupational therapy (OT) for the treatment of the enrollees visual perceptual/motor skill deficits. Findings:  The physician reviewer found that the patient is a full-time student and handwriting is an integral component of his activities of daily living. He has been formally evaluated and was found to have impaired visual-perceptual and motor integration skills. The patients provider also documented motor function delays. OT is an appropriate intervention and can potentially improve the patients ability to coordinate his visual-perceptual skills and his hand-finger movements and restore normal hand/finger motor function.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old female enrollee requested mental health residential treatment center services and prospective mental health residential treatment center services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition. According to the discharge summary, the treating psychiatrist notes that the patient did well overall in terms of aggressiveness, anger and agitation. The patient had some response to Abilify. In addition, psychological testing was started but not completed. This testing could be performed as an outpatient, and the results may prove useful in helping to determine what types of treatment would help this patient. Therefore, the services could have been continued in a less intensive environment. The patient was not a severe behavior problem and was not making suicidal or homicidal threats or at risk of harming herself. The medication management she was receiving could have been accomplished at a lower level of care.  Furthermore, the request for prospective RTC services is not clinically indicated at this time. According to the patients psychiatrist, he felt that it would take at least a month before the patient displayed problematic behaviors. As such, based on the clinical records provided for review, ongoing treatment can be provided at a lower level of care. Given all of the above, her condition does not meet the medical necessity criteria for prospective residential level of care and can be safely been treated at a lower level of care. For the reasons provided above, RTC level of care and prospective RTC services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 67-year-old male has requested minimally invasive lumbar decompression for treatment of his chronic low back pain.  Findings:  Two physician reviewers found that his medical records note tingling and numbness in the right leg.  The patient has been diagnosed with central stenosis at L4-5 and bilateral neural foraminal stenosis.  The clinical notes indicate that the patient has degenerative disc disease which has worsened over time.  His prior treatment has included facet joint nerve blocks, epidural steroid injections, medications, and radiofrequency ablation.  Per the submitted documentation, prior treatment has not resulted in long-term relief.  In this patients case, the requested minimally invasive lumbar decompression is likely to be superior over other treatment options.  Currently, this is an emerging procedure.  Although there have not been randomized double-blind trials in large populations, many studies have shown significant improvement with positive results.  In this patients case, there are limited treatment options.  The requested minimally invasive lumbar decompression is associated with minimal complications.  Thus, the requested services are likely to be more efficacious than other treatment options.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. In this case, the patient presented to the emergency department with acute onset of abdominal pain that had persisted and was accompanied by diarrhea. She was tachycardic on arrival. Laboratory testing revealed a significant leukocytosis and hematuria. This prompted CT imaging to rule out acute surgical pathology. The patients tachycardia was treated with intravenous fluids. Symptoms of ongoing abdominal pain with diarrhea in a patient with tachycardia and a leukocytosis meets the definition of an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. 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: Overturned

The parent of a three-year-old male enrollee has requested coverage for speech and language therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the role of speech and language therapy in autistic spectrum disorders is well published in the medical literature. Numerous peer reviewed articles recommend or demonstrate evidence for speech and language therapy for children with autism. While there have been few studies offering a direct comparison of methods, many experts believe that young patients with autism benefit from intensive, early intervention which focuses on increasing the frequency, form, and function of communicative acts. Pauls study indicates that intervention methods drawing from a range of philosophies and utilizing varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors. In this case, the patient has been receiving therapy with a picture exchange system, a modality that has demonstrated effectiveness, as concluded by Millar and colleagues.  While it is true that this patient does not exhibit defined trauma, surgical intervention or craniofacial abnormalities that would lead to the need for speech and language therapy, he does carry a diagnosis of autistic disorder, for which the standard of care is speech, language and communication therapy. Given this patients recent advances and relatively mild delays, the patient should be reassessed through the school system in the near future to determine if his needs can be accommodated through that venue. In the interim, the Health Plan should provide speech and language services in light of the patients current deficits. Given this patients current documented delays, services for speech and language therapy should be provided for a minimum of four months in order to support his recent significant gains. At that point, given the patients expected transition to the school system and his lack of need for intensive therapy, an evaluation should be made through the school system to determine the need for continued therapy. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female has requested hip resurfacing for treatment of osteoarthritis.  Findings:  The physician reviewer found that the patient is not a  reasonable candidate for hip resurfacing. Long term data has not demonstrated superior wear results with hip resurfacing as this is only a theoretical benefit in terms of 10 to 15-year follow-up.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested Norco 10-325mg oral tablets, 6 pills per day, and weekly blood testing for evaluation and treatment of her pain and anemia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication and testing in this clinical setting.  The current standard of care for chronic pain as well as pain associated with peripheral neuropathy is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Short release/acting opioids are associated with a high risk of dependence and tolerance.  Therefore, long-term administration is not recommended.  Frequent blood draws to assess anemia would be indicated in a symptomatic patient.  In this patients case, she does not present with an indication for weekly blood draws.  All told, Norco 10-325mg oral tablets, 6 pills per day, and weekly blood testing are not medically necessary for the evaluation and treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-five year-old female with a fibroid uterus is requesting authorization for another procedure to accomplish embolization of the contralateral side.  The patient had undergone a previous uterine artery embolization, but the right uterine artery apparently went into spasm and embolization could not be achieved.Reviewers Findings:The reviewing physician found that the procedure at issue is not a second embolization, but rather, a continuation of the original procedure.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a surgical consultation for hemorrhoidectomy.Hemorrhoids are a collection of blood vessels around the anus that are typically asymptomatic. The most common complaint associated with hemorrhoidal disease is rectal bleeding or itching during bowel movements. Hemorrhoids are classified into internal, external and mixed hemorrhoids. Their initial treatment includes dietary (increasing dietary fiber) and lifestyle modification. If the initial treatment is not sufficient, then medications for symptomatic relief are recommended. Topical ointments containing anesthetics, steroids, emollients, antispasmodic agents and antiseptics are often tried, but there is a lack of evidence that supports the efficacy of these treatments. Additional treatment includes sitz baths. Referral to a specialist is indicated for individuals with symptomatic internal hemorrhoids that have been refractory to at least six weeks of medical treatment, individuals with symptomatic high-grade internal hemorrhoids (prolapse of tissue), or individuals with thrombosed hemorrhoids.The submitted documentation does not support that a surgical consultation for a hemorrhoidectomy is medically necessary. In this case, there is no documentation to support that the patient has failed treatment with dietary and lifestyle modification. Submitted records do not identify the patients symptoms or what type of hemorrhoids she has. Under these circumstances, the medical necessity of a surgical consult is not established due to a lack of details of a failure of conservative care or an indication that the patient has high grade hemorrhoids with tissue prolapse. Accordingly, a surgical consultation for a hemorrhoidectomy is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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: An enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her overactive bladder.  Findings:  Three physician reviewers found that based on the current peer-reviewed medical literature, PTNS is an appropriate and indicated third-line treatment option for patients with overactive bladder. In this case, standard, proven first-line and second-line treatments have not reportedly been used prior to resorting to PTNS, which is reserved for patients who have failed treatment with standard therapies. Given these findings, the PTNS treatment was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were not and 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:  All three reviewers are board certified in urology 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.