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

A male enrollee requested substance abuse residential treatment for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found thatthe patient had concerning comorbidities and severe addictive illness.  Further, he previously failed a residential placement during the episode of illness.  Prior to admission, he was consuming benzodiazepines in dangerous amounts.  He was having relationship distress and lacked a sober support network.  Based on these factors, discharging the patient early would have more than likely resulted in relapse.  The duration of the service was within typical community standards.  The residential level of care was reasonably expected to improve his condition while preventing a more serious episode of illness.  All told, substance abuse residential treatment was medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 32-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient had been suffering from emesis (vomiting) for two days and diarrhea for one day prior to her visit. Although she had nausea, there is no indication that she was continuing to experience vomiting on the day she presented to the emergency department. She denied any hemorrhage or abdominal pain. Her vital signs were described as normal. Her physical exam was unremarkable. The only testing performed was a urinalysis. No blood testing was ordered. There is no documentation that the patient was dehydrated or unstable, either by vital signs or lab data. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe she was at risk of serious jeopardy to her health, serious impairment to bodily function, or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet Californias definition of an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery. This patient is an adult who began evaluation for bariatric surgery with documentation of obesity with a BMI that was at least 35 kg/m2, and has ranged from 38-39 kg/m2, with serious comorbid conditions including diabetes, sleep apnea, and hypertension. The patient completed supervised weight loss efforts in the past, and completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or psychological barriers to surgery. The patient meets all nationally accepted criteria for bariatric surgery including the published guidelines from the American Society for Metabolic and Bariatric Surgery (ASMBS). Accordingly, the requested gastric bypass surgery is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification in bariatric 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: Experimental/Investigational
Decision: Upheld

The parent of a 17-year-old male has requested transcranial magnetic stimulation for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that the patient has been diagnosed with major depressive disorder and per the submitted documentation, his symptoms include hopelessness, suicidal ideation, poor concentration, anhedonia, and isolation.  The patients medical history does not reflect comorbid anxiety disorders or a history of substance abuse/dependence.  His prior medications have included Wellbutrin, Zoloft, Prozac, Lexapro, Cymbalta, Abilify and Adderall.  The superior efficacy of the requested services has not been established in this clinical situation. There is a lack of literature supporting the use of transcranial magnetic stimulation in the child and adolescent population.  The documentation noted that the patient experiences auditory hallucinations.  As per American Psychiatric Association guidelines, electroconvulsive therapy is superior over transcranial magnetic stimulation for patients with psychotic symptoms.  For patients whose symptoms have not responded to medications, electroconvulsive therapy remains the most effective form of therapy and is recommended with substantial clinical confidence.  American Psychiatric Association guidelines note that the treatment of refractory depression may include augmentation strategies, such as mood stabilizers, atypical antipsychotics, stimulants and thyroid replacement.  The clinical notes indicate that the patients medications have included lithium, Abilify and Adderall.  However, it has not been demonstrated that these medications were offered in the current episode of treatment, at therapeutic doses, for adequate time frames.  Therefore, the submitted documentation does not demonstrate that the current episode is refractory.  All told, transcranial magnetic stimulation is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Rezum procedure (transurethral water vapor thermal therapy; CPT 53854).Findings:  The physician reviewer found that The Rezum System is a novel technique available to treat male urinary symptoms secondary to benign prostatic hyperplasia (BPH) due to an enlarged prostate. The Rezum technology uses water vapor therapy to create necrosis within the transitional zone, which eventually shrinks the prostate, thereby improving urinary symptoms. Overall, current medical literature does not support improved patient health outcomes with the Rezum procedure over current standard of care with transurethral resection of prostate (TURP). In addition, long-term outcomes of the procedure are largely unknown. On review of the available guidelines and literature, the Rezum procedure is not considered standard of care for the treatment of BPH refractory to medical therapy. For these reasons, the Rezum procedure (transurethral water vapor thermal therapy; CPT 53854) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Rezum procedure (transurethral water vapor thermal therapy; CPT 53854) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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 Abemaciclib (Verzenio) 100 mg twice per day. Based on the records provided for review, this patient with metastatic breast cancer was initially on a combination with Ibrance with good tumor response. However, she developed side effects, which resolved with discontinuation of Ibrance, but precluded continuation of her treatment regimen. Her provider recommended changing from fulvestrant to Arimidex and from Ibrance to Verzenio. A major advance in the treatment of ER positive HER2 negative metastatic breast cancer has been the addition of CDK4/6 inhibitors, such as Ibrance or Verzenio, to standard hormonal therapy. Randomized studies evaluating these combinations have shown a significant increase in progression-free survival, as well as overall survival (Finn, et al.). The National Comprehensive Cancer Network (NCCN) supports treatment with any of the three available CDK4/6 inhibitors in combination with either fulvestrant or Arimidex in this patients clinical setting. Given the patients initial positive response, but inability to tolerate Ibrance, it is reasonable to offer a new combination, using a similar medication. Therefore, the requested Verzenio 100 mg twice per day 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 internal medicine with subspecialty certification in medical oncology 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

The patient is a 64-year-old male who developed gynecomastia secondary to treatment with Proscar for benign prostatic hypertrophy. The patient has discontinued his use of Proscar. The submitted notes indicate the patient has A-cup gynecomastia with a 3 cm breast bud under each areola. The patients physician has recommended breast reduction surgery. The Health Plan has denied authorization for the requested procedure on the basis it is not medically necessary for treatment of the patients condition.While the patients photographs do display gynecomastia, the condition represents a cosmetic rather than a functional problem for this patient. Documentation from the patients provider does not establish that the requested procedure is reconstructive in nature. The medical records and photographs show that the patient has mild gynecomastia. Based on the American Society of Plastic Surgery Guidelines, the clinical findings do not support surgical intervention at this time. Therefore, I have determined that the requested procedure 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: The patient has requested authorization and coverage for custom ankle-foot orthotics (AFOs) and shoe lifts. The use of AFOs for patients that suffer with foot drop is well established in current medical literature. Medical literature notes a significant beneficial effect from customized AFOs in terms of spatial temporal gait parameters and ankle kinematic parameters compared to the barefoot gait of adults with drop foot gait. Medical literature reports that a study of 28 children with cerebral palsy showed that correction with an AFO is an effective treatment for equinus deformity. In this case, the records document that the patient has bilateral lower extremity equinovarus deformities. She used a wheelchair for ambulation but was also able to bear weight on her feet and walk. The patient was noted as using custom AFOs and shoe lifts that were worn down. Given that custom AFOs and shoe lifts can be tailored exactly to the specific biomechanical abnormalities of a patient with equinovarus type of foot drop, thus allowing for a better correction, the requested equipment is medically indicated. Therefore, custom AFOs and shoe lifts are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatry, 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 60-year-old female enrollee has requested psychiatric acute inpatient services for treatment of her eating disorder and depression.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines state that hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. This patient was severely depressed with ongoing suicidal and homicidal ideation throughout her admission. In addition, the records document poor impulse control which placed the patient at high risk for harm to self or others. Acute inpatient hospitalization was appropriate to treat the patients condition, consistent with standards of good medical practice and could not have been provided safely on an outpatient basis. For these reasons, the psychiatric acute inpatient services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for neurofeedback of the quantitative electroencephalogram brain scan. Findings:  The physician reviewer found that Electroencephalographic neurofeedback involves a real-time electroencephalogram (EEG) signal measurement, immediate data processing with the extraction of the parameter(s) of interest, and feedback to the individual in real-time. Using such a feedback loop, the individual may gain better control over the neurophysiological parameters by inducing changes in brain functioning and, consequently, behavior. Current medical literature supports its use as a complementary treatment for a variety of neuropsychological disorders and improvement of cognitive capabilities. In this case, given that this patient has several psychiatric diagnoses, the use of neurofeedback as a supplement to other psychiatric interventions was medically indicated. Therefore, neurofeedback of the quantitative electroencephalogram brain scan performed on 6/7/22 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested for L3-4 discectomy and fusion surgery for treatment of her lower back and leg pain. Findings:  The physician reviewer found that there is no MRI evidence documenting recurrent herniation. Furthermore, the interval since the patients last surgery has been relatively brief and further conservative management is an appropriate treatment course at this point in time. However, at this time the medical necessity of L3-4 spinal level discectomy and fusion has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested for Flector patch (1.3%) for treatment of her costochondritis. Findings:  The physician reviewer found that there is no evidence that this patient has undergone an omeprazole trial or a COX-2 inhibitor trial. The use of the diclofenac (Flector) patch prior to the use of either of the two above mentioned interventions is not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for nasal/sinus endoscopy surgery with balloon ostial dilation. The enrollee has diagnoses of obstructive sleep apnea, chronic sinusitis, nasal congestion, and a deviated nasal septum. After nasal endoscopy, she was treated with naso-topical therapy, including steroids, nasal saline, and humidification to her continuous positive airway pressure device. After months of treatment, the provider noted the enrollee remains symptomatic and that naso-topical therapy has failed. The provider recommended endoscopic sinus surgery for short and long term relief of her condition. This enrollee is not a good candidate for the nasal/sinus endoscopy surgery with balloon ostial because there is no postoperative computed tomography scan of the sinuses, documentation of specific medical therapy, or clinical complaints and findings in the medical records that would validate the need for the requested procedures. Medical records are insufficient to support the need for this procedure.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in otolaryngology 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.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested Phisohex 3% for treatment of her MSRA infection. Findings:  The physician reviewer found that while there is no proof that over the counter skin cleansers containing triclosan are ineffective for MRSA, the most effective treatment for elimination of MRSA skin carriage in the United States is the use of either hexachlorophene (in the concentration present in Phisohex) or chlorhexidine, another prescription medication. As such, the use of Phisohex is medically appropriate and clinically indicated for treatment of the patients recurrent MRSA infection.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested Gardasil (HPV vaccine) for treatment of his Crohns disease.  Findings:  The physician reviewer found that the current Centers for Disease Control (CDC) recommendations for the HPV vaccine include use in males aged 9 to 26 years of age. The vaccine is less immunogenic among patients ages 16 to 26 than in those 9 to 15 years of age. The CDC recommendations also note the increased risk for infection and the associated anal cancer among homosexual males. This patient is at higher risk of infection with HPV as a homosexual male but is at relatively low risk since he is monogamous. He might have a lessened immune response to the vaccine as a result of his immune suppression from the Remicade. However, based on the guidelines from CDC, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested Botox therapy for the treatment of her cervical dystonia. Findings:  The physician reviewer found that there is documented scientific evidence demonstrating that Botox is an effective and appropriate procedure for the treatment of cervical dystonia. Available evidence demonstrates that approximately 75% of patients with cervical dystonia respond quickly to Botox therapy with sustained relief. This patient has an established diagnosis of cervical dystonia. Botox therapy is indicated and will likely provide significant benefit for her condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center services provided on 6/10/18 forward. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does not support the medical necessity of the services at issue. The patient presented to the residential treatment center with a history of substance use, which was mainly marijuana. The records noted that during treatment, the patient was cooperative, calm, and insightful into the patients psychological needs. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms. The records did not indicate other severe psychiatric symptoms that would require intensive psychiatric care. The patient did not express suicidal ideation or severe mood lability during the disputed dates of service. The patient did not have self-harm behaviors and was medically stable. The medical record did not indicate the presence of any withdrawal symptoms. The American Society of Addition Medicine criteria for level of placement can be applied to this patients presentation to help determine the appropriate level of care. With regards to acute intoxication and/or withdrawal potential, the patient has a risk rating score of zero due to lack of withdrawal. In terms of biomedical condition and complications, the patient has a risk rating score of 0-1 due to no active serious medical problems. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0-1 indicating some mild issues that were noted to be under good control with medications. In terms of readiness to change, the patient has a risk rating of 2 due to low motivation to change with some interest in continued treatment.  With regards to relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. With regards to recovery/ living environment, the patient has a risk rating of 1-2 due to no mentioned sober living environment. Overall, the patients presentation suggests risk-rating scores that range from 0 to 2. This overall risk rating is consistent with intensive outpatient services. In summary, residential treatment center services provided on 6/10/18 forward were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested   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.