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

An enrollee has requested authorization and coverage for voice and communication therapy services. The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that treatments that may be medically necessary treatments for gender dysphoria include voice therapy and/or surgery (WPATH Position Statement on Medical Necessity, 2016). The WPATH has also stated that voice and communication therapy may help to alleviate gender dysphoria and be a positive and motivating step towards achieving ones goals for gender role expression (WPATH Standards of Care, 2012). In this case, the patient has a diagnosis of gender dysphoria and seeks the assistance of a qualified voice and communications therapist in order to establish greater congruence with her gender identity. Authoritative guidelines from the WPATH support that voice and communication therapy may help to alleviate gender dysphoria. Under these circumstances, the requested voice and communication therapy services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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

The patient is a 57-year-old male who had a liver transplant in July 2002 for hepatitis C and hepatocellular carcinoma.  He had recurrence of the hepatocellular carcinoma in the transplanted liver in early 2004 and was treated with radiofrequency ablation.  On a CT scan of the chest, abdomen and pelvis performed in November 2005 a new enhancing 3.5 cm mass was found in the posterior portion of the liver.  The patient has an elevated alpha fetoprotein (AFP) level and the lesion is likely to be recurrent hepatocellular carcinoma.  A PET scan was ordered prior to possible surgery.  The Health Plan denied authorization for the PET scan based upon their determination that it is not medically necessary.Hepatocellular carcinoma shows variable FDG activity. This is thought to be from differing amounts of FDG-6-phosphatase activity.  PET positive activity in hepatocellular carcinoma can range from 0-64%.  For evaluation of the patients new liver lesion, a PET scan would not be helpful because a biopsy is needed to determine whether the lesion is PET positive or negative. Once the etiology of the new liver lesion is known, a PET scan would be helpful for the patients management in ways such as following the response to therapy or the detection of metastatic disease if the liver is proven to be PET positive.  However, at this time a CT-guided liver biopsy would be recommended as the next procedure for this patient. Therefore, I have determined the requested PET scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continued residential treatment center (RTC) services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). On evaluation, the patient was at some risk of harm (score 2). The patient demonstrated moderate functional impairment (score 3). The patient has significant co-morbidity (score 3). The patient is noted to have a mildly stressful environment (score 2) with supportive parents (score 2). The patient has demonstrated equivocal resiliency and response to treatment (score 3) with a limited history of prior treatment. The patient has been obstructive to treatment (score 3) and is noted to make comments about wanting to change her behavior but remains ambivalent about stopping her substance use. This composite score of 18 meets the criteria for an intensive outpatient program (IOP) treatment. The patient continues to need treatment for her cannabis use disorder, major depressive disorder, generalized anxiety disorder, and ADHD, but this can be safely and adequately provided in a less restrictive environment. 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 psychiatry with expertise 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal surgery consisting of two-level lumbar fusion (CPT codes 20937, 22630, 22632, 22842, 63047 and 63048). The records provided for review document that this patient has failed over five years of conservative, non-surgical treatment for management of her low back and radicular leg pain. Given her symptoms and failure of non-surgical treatment, surgery is an acceptable treatment option. The patients foraminal stenosis due to disc height loss supports the requested restoration of disc space height through placement of an interbody device, or with complete resection of the facet joint, which then results in iatrogenic instability and requires instrumentation and fusion. The patients primary back pain due to disc degeneration is unlikely to respond to decompression alone. Lumbar disc arthroplasty is not recommended for two levels of degenerative disc disease. Thus, a two level spinal fusion is the appropriate surgical intervention. All told, the requested spinal surgery consisting of two-level lumbar fusion (CPT codes 20937, 22630, 22632, 22842, 63047 and 63048) is 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 neurological 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential level of care services for treatment of his behavioral health conditions.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this case, substance use was prominent.  However, the record did not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, community programming, family counseling or evidence-based psychotherapies and pharmacological strategies targeting his addictive illness during the episode of illness, as it appears that he concluded monthly therapy.  Further, the patient had no psychiatric or medical comorbidity.  He had an unremarkable physical examination and stable vital signs upon presentation.  The psychosocial assessment noted his motivation for recovery and strong support system.  This patients symptom complex was not consistent with a severity that would require treatment in a 24-hour supervised setting.  Additionally, there was no discharge summary, treatment plan or explanation opined by the treatment team articulating the necessity of the residential setting as opposed to well-organized, evidence-based substance use interventions delivered in a less restrictive setting.  In the absence of such clinical documentation, there is no evidence to suggest that a lower level of care would have been insufficient.  All told, residential level of care services were not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.
Appeal type: Urgent Care
Decision: Upheld

The parent of a five-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe their child 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 presented to a hospitals emergency room after two to three episodes of clear emesis (vomiting). He had potentially been exposed to human feces in a swimming pool earlier in the day. His symptoms had resolved, and he was in no distress upon presentation to the emergency room. Vitals were stable. He did not have diarrhea or bloody stool. The patient was described by the triage nurse as happy, smiling, playful, and comfortable. While the patients symptoms may have warranted a medical evaluation, that evaluation did not need to be provided on an emergency basis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140mg/ml.The submitted medical records do not support that the requested medication is medically necessary. While the patient has a mild elevation of low-density lipoprotein (LDL) cholesterol (129 off statins), there is no detailed documentation of cardiovascular disease, myocardial infarction (MI), transient ischemic attack (TIA) or stroke in the submitted medical records. The patients electrocardiogram (EKG) does not show a prior MI. She is reportedly intolerant of two statin medications, though at a higher dose (40-80mg atorvastatin) her LDL was 62 based on the labs and notes provided. The patient does not have familial hypercholesterolemia or objective documented atherosclerotic cardiovascular or cerebrovascular disease which would be an indication for Repatha PCSK9 therapy if titrated statins plus ezetimibe were ineffective or not tolerated.In addition, the submitted records do not document trials of lower dose (better tolerated) statin therapy combined with ezetimibe or other dosing strategies to achieve the desired LDL goals (Mancini, G., et al.). Therefore, the submitted records do not document clinical atherosclerotic cardiovascular or cerebrovascular disease, nor do they detail a failure of titrated statin/ezetimibe therapy in the setting of diabetes with other documented cardiovascular risk factors. Under these circumstances, the requested Repatha SureClick 140mg/ml is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned

The parent of a three-year-old male has requested psychological testing for evaluation of his autistic disorder.  Findings:  The physician reviewer found that young children are often referred for psychological evaluation because they appear to have features of autism, which can be difficult to assess given their limited social interaction and communication skills. According to a paper by Akshoomoff, Many features and behavior problems can further interfere with the accurate assessment of a young childs cognitive abilities, including difficulty maintaining attention, hyperactivity, sensory issues, and poor compliance, particularly in an unfamiliar setting. According to Akshoomoff, it is critical to identify cognitive strengths and weaknesses and developmental delays in a young child suspected of an autism spectrum disorder (ASD) as part of the initial diagnostic workup and to assist with treatment planning. A standardized psychological test can provide the clinician with a significant amount of information about the childs abilities and behavioral difficulties.In the case of this particular patient, it was medically necessary to perform a psychological evaluation to develop an individual treatment plan for the patients entire treatment team. It is very important to use his strengths and to enhance his weaknesses to develop a speech pattern by five years of age, which is one of the main prognostic factors in a patient diagnosed with an autistic spectrum disorder.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an increase in Percocet medication for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medical quantity.  She has been on Percocet without documentation of improved function or attempted weaning.  The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Other researchers reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested increase in Percocet medication is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested growth hormone treatment (Nutropin) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the purported growth failure is not apparent from the submitted growth chart. The patients growth remains well within the normal range. In addition, the patient had normal GH dependent insulin-like growth factor (IGF-1) and IGFBP-3 levels and a normal brain magnetic resonance imaging (MRI) scan. He had two GH stimulation tests which showed peak GH levels near the cut-off values of 10 ng/ml. Given these findings, there is insufficient evidence the patient is experiencing GH deficiency. Accordingly, GH therapy is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Labiaplasty Hypertrophy Correction surgery.Findings:  The physician reviewer found that The submitted documentation does not support that the requested services are medically necessary. In this case, the patient underwent bilateral labiaplasty for labial hypertrophy four years ago. She was seen post-operatively with no documented complaints or asymmetry on exam. The submitted medical records reflect that the patient had a Gynecology office visit 17 months ago for confirmation of pregnancy, however, these records do not include any report of symptoms of asymmetry or pain. Based on the patients clinical documentation, the patient has not had her reported symptoms of asymmetry or pain evaluated or examined by a clinician. Under these circumstances, the requested Labiaplasty Hypertrophy Correction surgery is not medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient has reported that following bilateral labiaplasty for labial hypertrophy, she has noticed asymmetry with an elongated left labia that is causing discomfort for her, both mentally and physically. The patients submitted Gynecology records do not reflect that the patient has seen a specialist in Obstetrics and Gynecology to review her symptoms and examine her labia for asymmetry and scarring. There is therefore no documentation of an abnormal structure of the body at this time. Accordingly, the requested Labiaplasty Hypertrophy Correction surgery is not reconstructive in nature for treatment of the patient at this time.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's medical condition and not reconstructive in nature for treatment of the patient at this time. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 38-year-old male enrollee has requested for a VPAP (variable positive airway pressure) device for treatment of his sleep apnea (OSA). Findings:  The physician reviewer found that while the patient does have OSA and also had central apneas with the use of BiPAP, a thorough review of current literature does not support the use of VPAP as standard of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominoplasty.The submitted documentation does not support that the requested services are medically necessary. The World Professional Association for Transgender Health (WPATH) has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The WPATH also includes non-genital, non-breast surgical interventions among the listed surgical procedures for the treatment of patients with gender dysphoria. In this case, however, while the patient states that the requested abdominoplasty is sought as a medically necessary part of his female-to-male transition, abdominoplasty may be performed for cosmetic purposes as well, and there is not sufficient documentation that the requested abdominoplasty would be performed as a treatment for gender dysphoria. Therefore, the requested abdominoplasty is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patient's 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan. Findings:  Three physician reviewers found that Leiomyosarcoma is a type of sarcoma that commonly arises from soft tissue and occasionally arises from the bone. It accounts for approximately 7% of sarcomas. It is most commonly treated with chemotherapy, and if possible, complete resection. Adjuvant radiation therapy may also be needed. In this patients case, although she was noted to be in remission, there are residual masses in the sacrum and T10 regions. The advantage of PET/CT scanning over routine CT scanning is that PET can demonstrate increasing metabolic activity in a lesion that appears to be chronic or scarred. In this patients case, the medical evidence supports evaluation with PET scanning. Thus, the requested PET scan is likely to be of greater benefit than other available options for evaluating this patient. Final Result: 3 of 3 reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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.