Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

The parent of an 18-year-old male enrollee has requested continuing emergency services for 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 patients 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. Review of the submitted documentation indicates the patient was advised to seek post-exposure prophylaxis (PEP) for environmental exposure to bats by the visiting states health department. Rabies is an infection contracted by mammals and spread through contact with an infected animals saliva via bite wounds, open cuts in the skin, or mucus membranes. Once symptoms commence, the disease is almost uniformly fatal. The most important reservoir for rabies in the Unites States are bats. Of the 21 cases of human rabies in the United States between 1996 and 2006, 19 were contracted from bats. However, only half of those patients reported being bitten. Therefore, transmission of rabies from bats has occurred with seemingly unimportant (not-biting) exposure. Accordingly, the Centers for Disease Control (CDC) recommends PEP, when a bat is found indoors with someone who might be unaware that a bite or direct contact had occurred (such as someone sleeping, an unattended child, or a mentally disabled person.) (Marx and colleagues). In this patients case, the PEP protocol was appropriately initiated. In all cases, once the decision has been made for immunoprophylaxis, the entire vaccine series must be completed and hence the patient was advised to return to the emergency department for follow-up service.  The vaccine is generally not carried in any physicians office, but stocked only in the emergency department. As such, a parent in these circumstances would reasonably believe his or her child was at serious risk of harm without the emergency department services on the dates in questions.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested panniculectomy revision surgery for the treatment of her excessive abdominal skin and scarring. Findings:  The physician reviewer found that the patients excess skin is not an abnormal structure. She has skin redundancy that is consistent with her obesity. She has normal skin that is simply redundant.  The requested surgery will improve appearance but will not improve function.  The improvement in appearance will be relatively mild, as the patients deformity is not severe.  Her mild skin excess and midline abdominal scar are not significantly disfiguring, and her abdomen is easily covered by clothing. The requested procedure is not medically indicated because it will not correct a significant deformity and will not improve function. The patients concerns are cosmetic, and the planned operation is a cosmetic procedure with the only purpose to improve appearance.
Appeal type: Medical Necessity
Decision: Upheld

The representatives of a 17-year-old male enrollee requested authorization and coverage of a standing power-operated vehicle (POV) for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested equipment is not medically necessary for assistance with the enrollees mobility.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Viibryd 80 mg (40 mg twice a day). As noted in the medical literature, Viibryd can be safe and effective when dosed up to 80 mg daily when taken in conjunction with metabolic inducers. This patients provider noted that the patient is an ultrarapid metabolizer of medications, which is considered a similar clinic scenario. In addition, Wang and colleagues reported on several non-published studies of Viibryd that have demonstrated safety in the medication even when dosed up to 100 mg daily. This patient has been managed on Viibryd 80 mg daily without adverse effects for her treatment-refractory depression. In addition, the patient has failed treatment with numerous medical therapies in the past, even at the highest recommended doses. Given the clinical effect without adverse effects and the patients long history of treatment-refractory major depressive disorder, continued treatment with Viibryd at 80 mg daily is consistent with current recommendations. Therefore, the requested Viibryd 80 mg (40 mg twice a 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 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

The patient is a 58-year-old woman with documented dermatochalasia and blepharochalasis. The patient has experienced decreased vision and peripheral vision. The patients provider has recommended bilateral blepharoplasty and browpexy. The Health Plan has authorized a browpexy but indicates that concurrent blepharoplasty is not medically necessary. The Health Plans denial should be overturned. The submitted evidence reveals the presence of visual symptoms, documented visual field impairment, and dermatochalasis. As such, a browpexy is a medically indicated and necessary procedure. While it is likely that a browpexy will resolve a majority of the patients problem, it is also likely that the patients surgeon may need to remove some of the patients lid skin during the procedure in order to correct the patients condition. Therefore, the patients request for a bilateral blepharoplasty is medically reasonable and appropriate and should be authorized.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A fifty year-old male with end-stage liver disease due to hepatitis C and cirrhosis is requesting authorization and coverage for inpatient methadone detoxification.  Reviewers Findings:  The reviewing physician found that the medical literature demonstrates methadone detoxification can be performed safely on an outpatient basis with a decrease of methadone, as tolerated, coupled with treatment of associated symptoms.  The Health Plan denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested CPT codes 83090 (homocysteine) and 86141 (C-reactive protein) for evaluation of his family history of coronary artery disease.  Findings:  Two physician reviewers found that in this patients case, C-reactive protein and homocysteine testing performed on the date in question were not likely to have been superior over other available methods of evaluation.  There is a lack of evidence demonstrating that lowering homocysteine levels in this clinical setting improves cardiac outcome.  Per the medical records, this patient was on statin therapy on the said date.  Although there is some evidence supporting evaluation with C-reactive protein levels in patients on statin therapy, these studies tend to involve patients with existing atherosclerotic heart disease, and not patients on statin therapy for primary prevention, such as in this case.  Therefore, the superior efficacy of the services at issue has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy, at a frequency of one time per week for one hour each session. Findings:  The physician reviewer found that The current medical literature does not support the requested speech therapy, at a frequency of one time per week for one hour each session as medically necessary for treatment of this patients expressive language disorder. Law and colleagues conducted a review that cited 25 research studies and found that speech therapy was effective for articulation disorders including the /r/ sound. However this was less effective for syntax disorders. The research studies primarily looked at children ages younger than 10 years of age. Novaes and colleagues showed improvements in each of the children and reported that speech therapy was stopped by age 8. The study by Lousada and colleagues also noted that therapy was ceased by age 9. Overall, speech therapy may still be helpful for this patient. However, it is not medically necessary to continue speech therapy for articulation disorders beyond age 10. 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 pediatrics with sub-specialty certification in neurodevelopmental and behavioral pediatrics 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

A 62-year-old female enrollee has requested for selective internal radiation therapy using Yttrium-90 microspheres (SIR-Spheres) for treatment of her stage IV pancreatic carcinoma with liver metastasis.  Findings:  Three physician reviewers found that there are multiple prospective and retrospective studies demonstrating the use of Y-90 microspheres for metastases for colorectal cancer. The FDA has in fact approved the use of SIR-Spheres for this indication. Thus, treatment with SIR-Spheres is considered safe and effective for certain indications. At issue in this case is the use of SIR-Spheres for carcinoid tumors. In that regard, the most recent National Comprehensive Cancer Network (NCCN) guidelines include radioembolization as an accepted treatment with a level of evidence of 2A.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a lumbar medial branch block for treatment of her medical condition.  Findings:  The physician reviewer found that this patient has physical exam findings, pain complaints and diagnostic imaging which are all concordant for lumbar facet arthropathy. The MRI and prior treatments have been aimed at axial and lumbar radicular pain and she has not responded adequately. Facet medial branch blocks are an appropriate next step given her findings on exam and on imaging. Thus, the requested for lumbar medial branch block is medically necessary for treatment of the patients medical 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 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

A 79-year-old female enrollee has requested Oxtellar XR for treatment of her vertigo and meningioma.  Findings:  The physician reviewer found that based on review of the available records, the patient has a history of dizziness and has been on Trileptal. The patient has some symptoms which the provider thinks are most likely from benign positional vertigo. The provider has recommended either taking an additional dose of Trileptal 300 at mid-day or changing to the extended release formulation. While the extended release version of the drug has fewer fluctuations in blood levels, an extra dose at mid-day of Trileptal should be tried and may be successful (Leppik and Hovinga; Steinhoff and Wendling). If the patient has benign positional vertigo, there is no expectation for improvement in symptoms using the extended release version. All told, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. This patients records do not support the medical necessity of RTC services. This patient presents with some risk of harm (score 2) as the medical records indicate that the patient has not been actively suicidal and has not engaged in self-harm, but has a history of suicidal ideation. The patient demonstrated moderate functional impairment (score 3). While at home, the patient was noted to run away from home, abuse substances. However, while in treatment, the patient has demonstrated appropriate daily functioning as evidenced by intact activities of daily living and cooperation with his providers. The patient has some co-morbidity (score 2) given his recent substance abuse but no reported medical issues. The patients recovery environment is mildly stressful (score 2) as he is noted to have good relationship with his family and he denied stress at home of any significant nature. Overall, the patients recovery environment is supportive (score 2) as his parents are involved in his treatment. Further, although the patient reportedly demonstrated limited response to prior treatment (score 3), he has positively responded to the services and medications provided during this admission. Specifically, the patient has not exhibited significant mood or anxiety symptoms. The records suggest that any acute symptoms the patient demonstrated on admission have been resolved. The providers report that the patient has responded well to psychotropic medications and he has made progress in family therapy as well. The treatment progress notes did not indicate severe behavioral issues or any violent outbursts. The patient has been constructive in treatment (score 2) with documented active participation, and his parents have also worked well with the patients providers (score 2). This gives the patients presentation a composite score of 18, which correlates with intensive outpatient services. Thus, the patient was a candidate for treatment in a less restrictive setting. All told, the RTC services provided were not and are not medically necessary for treatment of this patients behavioral health issues. 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard fecal testing performed for evaluation of the enrollee, who has a history of colon polyps. Findings: Three physician reviewers have found that Cologuard is not standard of care at this time. Cologuard is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect most (but not all) adenomas if they have high-grade dysplasia. However, the limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard, raising concern that Cologuard may have missed cancer. The evidence of the impact of Cologuard on patient care or health outcomes is lacking. There is not a consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. Finally, Cologuard is studied for average-risk patients, and this patient has a history of unspecified polyps which may have placed her in a higher-risk category. For these reasons, Cologuard fecal testing performed was not likely to be more beneficial for evaluation of this patient than other available modalities.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviews are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned

The patient is a 40-year-old man with severe degenerative joint disease of the right hip. The patient engages in a high level of activity. The patient has consulted an orthopedist who has recommended a hip surface replacement arthroplasty. The Health Plan has denied authorization for the requested procedure indicating that it is considered investigational.At age 40 a surface replacement arthroplasty is a better option than a conventional total hip replacement because it spares more bone for revision hip surgery. This is an important concept in younger patients who require total hip replacement at less than 50 years of age. Additionally, the submitted literature lends great support and credibility to the procedure. It is certainly the best available option for relatively young total hip replacement candidates at the present time. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anesthesia services provided during an esophagogastroduodenoscopy/colonoscopy for the treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This 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 comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, anesthesia services during an esophagogastroduodenoscopy/colonoscopy 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 anesthesiology 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 Diclegis.Nausea and vomiting are common symptoms associated with early pregnancy. Hyperemesis gravidarum is defined as severe vomiting resulting in hypovolemia and weight loss and is less frequent. Symptom severity and impact on quality of life largely dictates the management options for nausea and vomiting. Treatment approaches include dietary/lifestyle changes, prescribed medication, and, if needed, hospitalization for parenteral fluids for patients who fail to respond to outpatient management. The American College of Obstetrics and Gynecology supports combination doxylamine-pyridoxine when other treatments fail to improve symptoms. Formulations of doxylamine-pyridoxine are available under various names, including Diclegis. Combination doxylamine-pyridoxine has been shown to be effective for the treatment of nausea and vomiting of pregnancy, and the combination appears to be more effective than either drug alone. There is sufficient support for the requested medication in this clinical setting. Therefore, Diclegis is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.