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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) level of care services. Applying the CALOCUS framework, this patient meets the criteria for admission to RTC level of care. The patient has been at significant risk of harm (score 3), due to history of multiple suicide attempts and recent self-harm. The patient has demonstrated serious functional impairment (score 4) given her consistent conflict with her parents and her peers at the RTC. The provider noted that the patient has a disheveled appearance. The patient failed treatment at the PHP level of care, which required transition to RTC. The patient has significant co-morbidities (score 3) due to autism spectrum disorder, substance use, and PTSD. The patients recovery environment is moderately stressful (score 3) considering her history of sexual assault and family conflict. The patients recovery environment is supportive (score 2) due to her parents engagement in therapy and treatment planning. The patient has exhibited poor response to treatment (score 4) with a lack of progress despite previous PHP treatment. The patient has been incompletely engaged with treatment (score 3). The providers report that the patient has shown difficulty with inappropriate behaviors while at the RTC. This gives the patient a composite score of 20, which is consistent with medically monitored community based services. However, due to score of 4 on functional impairment and a score of 3 on environmental stressors, the recommended level of care in this case is Level 5, medically monitored residence based services. Furthermore, the patient qualifies for Level 5B, intermediate stay medically monitored residence based services due to her history of suicidality, interpersonal conflicts, co-occurring mental health and substance abuse issues, and previous failure of treatment at PHP level of care. Per CALOCUS guidelines, the length of stay at this level of care usually does not exceed 60 days. This patient received 18 days of care at this level, and was still exhibiting significant symptoms at the time of discharge. Therefore, the requested RTC level of care services are medically necessary for 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 * 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 63-year-old female enrollee has requested reconstructive surgery to remove keloid scars for the treatment of her condition. Findings:  The physician reviewer found that the patients keloid scars are painful.  A study by Bock and colleagues found that keloids significantly impair quality of life when they cause pain, pruritis or restriction of mobility.  A study by Lee and colleagues found that pain and pruritis are common keloid symptoms, and the history of pain from the ear keloid is consistent with the known natural history of keloids.  This patients keloid is painful enough to interfere with her ability to sleep.  Treatment of the painful keloids is appropriate to treat the patients pain and improve her ability to sleep and the quality of her life.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of botulinum toxin injections for treatment of the enrollees temporal headaches, myofascial pain dysfunction syndrome and grinding of teeth.  Findings: The physician reviewer found that the medical literature does not support the requested services in this clinical setting. There have been various treatment modalities of MPD ranging from conservative therapies such as heat, physical therapy, and splint therapy to more invasive measures including oral medications, direct muscle injections, or dry needling. In regards to treatment with Botox injections, there is a lack of controlled clinical trials showing the benefits of Botox injections to patients with MPD. Given the lack of randomized clinical trials to establish therapeutic effects and protocols, the requested Botox injections for treatment of this patient, are not medically necessary.Final Result: The reviewer determined that 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 oral facial and maxillary 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

An enrollee has requested authorization and coverage for Xifaxan 550 mg three (3) times a day for 14 days. Xifaxan (rifaximin) has proven highly effective in the treatment of small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication had greater effectiveness with fewer side effects than antibiotic alternatives. Results are sustained for several weeks after treatment. In this case, the patient has small intestinal bacterial overgrowth that has not responded to treatment with over-the-counter medications. The provider has recommended Xifaxan at a dose and duration that is consistent with the regimens used in studies which support the use of this medication to treat small intestinal bacterial overgrowth. Under these circumstances, the requested medication Xifaxan 550 mg three (3) times a day for 14 days is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in gastroenterology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested a gastric sleeve procedure for treatment of her diabetes with peripheral neuropathy, hypertension, and hyperlipidemia.  Findings:  The physician reviewer found that although this patient is obese with co-morbid conditions, morbid or clinically severe obesity with a BMI of at least 35 and serious co-morbid conditions is not determined. The patient does not meet the National Institutes of Health (NIH) guidelines. Although low BMI bariatric surgery is being evaluated with ongoing clinical trials at this time, low BMI guidelines are not yet available as standard practice to properly guide in patient selection and technique. All told, the requested bariatric surgery has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a custom oral appliance (E0486NU) for treatment of the enrollee, who has been diagnosed with obstructive sleep apnea.Findings:  The physician reviewer found that there is a lack of support for the requested equipment in this clinical setting.  The patients Epworth Sleepiness Scale score was 3, which was normal, and there was no hypersomnia.  Per the clinical documentation, he was not obese.  He filled out a form from a dentist noting he was not tolerant of CPAP.  However, the records do not show that he had a CPAP titration study documenting the optimal setting for CPAP treatment. Additionally, there is no documentation that he was treated with CPAP for a three-month period by a medical sleep medicine specialist.  The home sleep studies that he had were not the standard of care facility-based sleep study with an attendant who is certified.  Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of liver mass.  Findings:  The physician reviewer found that radiofrequency ablation is commonly used for metastatic liver tumors which are not responsive to systemic chemotherapy. The survival of patients with metastatic breast cancer is variable, and local resection of metastases is standard of care in some instances. Targeted resection of metastases in select patients is a standard therapeutic approach and can confer a long-term survival advantage. The medical evidence supports the requested services in this patients case. Thus, the requested radiofrequency ablation of liver mass is likely to be of greater benefit than other treatment options. Final Result: Three physician 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 internal medicine with sub-specialty certification in medical 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.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-five year-old female with an abnormal enhancement and a suspicious lesion within the breast is requesting a follow-up MRI.  The patient has had negative mammograms in the past and has dense breast tissue. MR imaging of the breasts showed areas of abnormal enhancement within both breasts. A subsequent MRI and right breast ultrasound showed a suspicious lesion within the right breast that was only visualized with MRI. The patient was scheduled for MR-guided biopsy, but the right breast lesion was not visualized on that MRI study. The biopsy was cancelled and a follow-up MRI of the breast was recommended.Reviewers FindingsThe reviewing physician found that the patient had a suspicious lesion identified within the right breast that was only visualized with MRI. At the time of the scheduled biopsy of the right breast, the suspicious lesion was not present. Whenever there is a suspicious breast lesion that is not visualized at the time of the biopsy, it is medically appropriate to closely follow the patient to ensure that the lesion is indeed no longer present.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female has requested surgery to remove excess thigh skin.   Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of the requested procedure.  There is no documentation of office visits for or treatment of a skin condition related to the excess thigh skin.  The submitted medical records do not include a physical examination describing the extent of any such skin condition.  The patients condition does not constitute an abnormal structure of the body, given the lack of medical record documentation of a functional deficit or skin condition related to the excess thigh buttock skin.  The photographs do not demonstrate an excess of skin that would be sufficient to prevent ambulation.  The requested surgery would be performed to improve appearance, but not function.  The requested surgery does not meet the expanded concept of medically necessary reconstructive surgery defined in California law.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech and language delay.  Findings:  The physician reviewer found that formal testing has demonstrated language delay in this child.  She has demonstrated a significant delay in her speech development.  Evaluation revealed a 54 to 65% deficit in receptive language skills and 65 to 77% deficit in expressive language skills. The patients language delay is directly related to failure of normal brain maturation and is a congenital defect.  The current medical literature supports speech therapy in this clinical scenario.  Goorhuis-Brouwer and colleagues evaluated speech-delayed children, such as this patient, and reported that such children are ideal candidates for successful speech therapy.  The article by Law and colleagues also supports speech therapy in this clinical situation.  All told, the requested speech therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Actemra. According to the American College of Rheumatology (ACR) and Arthritis Foundation guidelines, In patients with juvenile idiopathic arthritis and polyarthritis and moderate or high disease activity receiving DMARD monotherapy, adding a biologic is conditionally recommended over changing to triple DMARD therapy. In addition, the guidelines do not mandate that a tumor necrosis factor inhibitor (TNFi), such as Enbrel or Humira, must be the initial biologic drugs utilized in the treatment of juvenile idiopathic arthritis. The guideline states that, The class of initial biologic is not specified in the recommendations again due to lack of comparative data and the consideration that non-TNFi biologics may be preferred in certain scenarios based on patient-level factors. The guidelines indicate that alternate biologic drugs, such as Actemra, is an acceptable option as initial biologic therapy in the treatment of juvenile idiopathic arthritis. In this case, the patient is on disease modifying antirheumatic drug (DMARD) monotherapy with oral methotrexate 15 mg weekly with persistent inflammatory arthritis symptoms. According to the guidelines, the addition of biologic therapy is appropriate for this patient. These guidelines also indicate that Actemra is an acceptable and appropriate initial biologic drug of choice for the treatment of active juvenile idiopathic arthritis. For these reasons, the requested Actemra is 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested cervical discectomy at L4-5 and removal of cervical plate at L5-6 for treatment of her cervical spine pain.  Findings:  The physician reviewer found that according to the Milliman Care Guidelines, cervical discectomy or microdiscectomy is considered to be medically necessary for cervical radiculopathy resulting from degenerative disc disease, disc herniation, or facet joint hypertrophy if there is unremitting radicular pain or progressive weakness secondary to nerve root compression and there has been a failure of a full trial of nonsurgical management. With regard to this patient, there is no significant radiographic evidence of degenerative disc disease, disc herniation, or facet joint hypertrophy at the level or side of her symptomatology. There is also no radiographic evidence of nerve root or spinal cord compression at this level.  Furthermore, she has not completed the full course of physical therapy prescribed by her provider. Also applying the Milliman Care Guidelines, anterior cervical fusion with or without instrumentation is considered to be medically necessary for degeneration of a spinal segment adjacent to a prior decompressive or fusion procedure when there is symptomatic myelopathy corresponding to the adjacent level and/or symptomatic radiculopathy corresponding to the adjacent level that is unresponsive to conservative care. Of import, is that this patient does not have any radiographic evidence of spinal cord compression or clinical evidence of myelopathy. She also does not have any radiographic evidence of nerve root compression, but she does have some evidence of radiculopathy. However, her conservative care options including an adequate trial of physical therapy have not been exhausted. As such, the two requested procedures, anterior cervical discectomy and fusion, are not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The mother of a four-year-old female enrollee requested authorization and coverage for sensory integration therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees sensory integration dysfunction. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The representatives of a 63-year-old male enrollee requested authorization and coverage of continued acute inpatient services for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A forty-six year-old female who has undergone gastric bypass surgery is requesting authorization of a mons pubis lift and bilateral brachioplasty.  Reviewers Findings:  The reviewing physician found that the records do not establish that the proposed procedures are medically necessary.  Correction of skin laxity following massive weight loss is typically considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative treatment. The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested authorization and coverage of nerve block/trigger point injections. The Health Plan denied the request indicating that the requested procedures are investigational/experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  Because the majority of physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment for the treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  There was documentation presented from her prior treatment outlining her history.  However, there was a lack of details provided regarding her reported substance use in terms of patterns, actual substances used, or quantification.  On admission, self-medication was endorsed.  However, this also was not described in detail, so it cannot be determined what, if any, impact it would have had on her daily functioning.  She had no history of failure at a lower level of care.  From the time of admission and throughout her stay, she was an active and engaged participant in group, individual, and family therapies.  Her medication regimen did not require residential level of care, and she had no medical comorbidity.  All told, residential treatment was not and is not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were not and 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 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.