Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Caris Molecular Intelligence tumor testing for evaluation of the enrollees mesothelioma.  Findings:  The physician reviewer found that standard treatment for mesothelioma is chemotherapy, with multiple first-line options.  Pembrolizumab can be considered as a subsequent treatment and is U.S. Food and Drug Administration (FDA) approved for patients with unresectable or metastatic solid tumors that progress on treatment or have no satisfactory alternative treatments and have microsatellite instability high (MSI-H) cancers. Therefore, there is support for microsatellite instability testing in this clinical setting. The patient did not require a full panel of molecular testing.  In this patients case, the panel performed was not standard therapy. In sum, the microsatellite instability testing portion of the services at issue was likely to have been superior over other available treatment methods. However, the submitted records fail to demonstrate the superior efficacy of the remainder of the services at issue. Final Result: Two of three reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty 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.Physician reviewer number two is board certified in internal medicine with sub-specialty 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.Physician reviewer number three is board certified in internal medicine with sub-specialty 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: Overturned

An enrollee has requested reimbursement for monitored anesthesia care (MAC) provided during a colonoscopy procedure. The submitted documentation supports that the services at issue were medically necessary. According to American Society of Anesthesiologists (ASA) guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE), during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures (which are performed with moderate sedation), and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. In this case, the patient underwent a complex large polyp resection requiring submucosal injection, polyp lift, and en bloc endoscopic mucosal resection, which meets the complex polyp resection recommendation of the American Society of Anesthesiologists. Under these circumstances, monitored anesthesia care (MAC) provided during the patients colonoscopy procedure was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for acute inpatient psychiatric services. At issue is whether the acute inpatient psychiatric services provided were psychiatric emergency medical services.Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder.In this case, the submitted treatment records reflect that the patient presented as an immediate risk for self-harm. The patient had suicidal ideation requiring treatment in a secure facility with close psychiatric monitoring and intervention. The treatment provided was effective in relieving the patients symptoms and was personalized to produce improvement. Appropriate evaluation and intervention with both medication and individualized treatment was provided. The patient's history, presenting symptoms, and current behavior comprised most of the risk factors for repeated suicide attempts. The patient had a psychiatric emergency medical condition during the psychiatric inpatient admission at issue. Therefore, the services provided were psychiatric emergency medical services as defined by California law.Final Result: The reviewer determined that the services at issue were psychiatric emergency medical services as defined by California law. Therefore, the Health Plans denial should be overturned.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

A 55-year-old male enrollee has requested a sacroiliac joint injection and possible rhizotomy if the injection is effective for treatment of his sacroiliitis.  Findings:  Two physician reviewers found that Sacroiliac joint injection and possible rhizotomy are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  The peer-reviewed literature supports the efficacy of sacroiliac joint injections and radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology only when patients are appropriately selected.  In reviewing the medical records, the patient is status post spinal fusion in the area to be treated.  The medical literature does not support the efficacy of these treatments at levels in which the medial/lateral branches are already disrupted such as that which may occur in spinal fusions.  All told, the current medical evidence has not established the superior efficacy of the requested sacroiliac joint injection and rhizotomy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 19-year-old male enrollee requested authorization and coverage of transitional residential psychiatric services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a comprehensive outpatient rehabilitation program that includes speech, occupational, physical and cognitive therapy for four (4) hours per day, three (3) to five (5) times per week for three months. Giustini and colleagues note that one of the main considerations when dealing with traumatic or nontraumatic brain injury is the complexity of the rehabilitation process. Smania and colleagues report that while functional and cognitive impairments in patients with severe traumatic, cerebrovascular, or anoxic acquired brain injury (ABI) may improve with time and rehabilitation, patients with cerebrovascular and anoxic ABI may have a more challenging clinical course. Skilled therapy services following an acute injury may promote recovery, maximize function given impairments, and transition patients to an independent program when feasible, or train caregivers for supervising a brain injury survivor's convalescence in the community. In the setting of severe brain injuries, deficits may remain severe despite intensive rehabilitation measures. In this case, the patient suffered acute brain in July 2019. She made substantive gains sufficient to reintegrate to the community in October 2019. The documentation shows that the patient has been undergoing intensive outpatient therapies since, but has been making mostly modest functional progress, and her overall status is largely unchanged. In this clinical setting, ongoing intensive outpatient multidisciplinary rehabilitation is not expected to marginally and positively impact the patients clinical or functional course or outcomes beyond any further recovery she may potentially experience with a program overseen by her caregivers, to include physical and mental exercises, and the passage of time. Therefore, comprehensive outpatient rehabilitation program that includes speech, occupational, physical and cognitive therapy for four (4) hours per day, three (3) to five (5) times per week for three months is not medically necessary for the treatment of this patient.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 physical medicine and rehabilitation 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 63-year-old female enrollee has requested selective internal radiation therapy (radioembolization) for treatment of her metastatic breast cancer.  Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other treatment options.  The use of selective internal radiation therapy has been tested in various contexts, both as a general strategy for local control of malignant disease of the liver, and also in more specific neoplastic contexts defined by tissues of origin.  In the latter category, for example, the treatment of neuroendocrine tumors in the liver is well supported.  Although the use of this modality for treatment of liver tumors from metastatic breast cancer is less defined, there is clinical data supporting the safety and efficacy of this approach.  This patient may obtain symptomatic relief if the tumor burden in her liver were reduced.  Thus, selective internal radiation therapy (radioembolization) is likely to be superior over other treatment alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male had cataract surgery on his right eye in 1996 and on his left eye in 1998. The patient has been experiencing pain in both eyes. Despite several visits to ophthalmologists, the exact cause of the pain has not been identified. The patient has requested removal of the ocular implants. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary.Though the patients vision is intact, he wishes to have the ocular implants removed. Review of the submitted clinical notes indicates an anterior chamber lens was implanted in the right eye. Use of an anterior chamber lens is not typical. However, there is no evidence of any issue with the patients vision or any description of corneal edema. There is no clinical justification for removal of the ocular implants at this time. The risks associated with the proposed procedure exceed any potential benefit that is likely to be obtained. Therefore, I have determined 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

The patient is a 64-year-old male who has had chronic lumbar pain following a lumbar fusion at L4-5 and L5-S1. Because of persistent pain, an analgesic discogram has been recommended. The patient has requested authorization and coverage for the proposed discogram, which the Health Plan has denied on the basis that this diagnostic procedure is not medically necessary.An analgesic discogram is likely to be helpful in this case as it will aid in the patients providers ability to establish a cause for the patients persistent pain. Discography has established clinical utility in cases such as this that appear to involve multi-level disc pathology. It can help render a diagnosis which is needed in order to formulate an adequate treatment plan. Analgesic discography is the appropriate next step for this patient and the procedure should be authorized. Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollees parent has requested authorization and coverage for excimer laser therapy. Current literature suggests that light therapy, in the form of excimer laser, is within the standard of care after the use of topical corticosteroids and calcineurin inhibitors. As this patient has failed treatment with topical steroids, tacrolimus ointment, and conventional NB-UVB, the requested excimer laser therapy is consistent with the medical literature. Given this support, the requested excimer laser therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 dermatology 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 is a 44-year-old female who has been diagnosed with ocular migraine headaches, allergic rhinitis, and left foot pain. The patient reported she had received four acupuncture sessions for the treatment of her ocular migraine headaches and left foot fracture with success. The patients foot pain was noted to be reduced by 25% and migraine headaches were less frequent due to treatment with acupuncture. The patient reported acupuncture had been helpful for the treatment of her migraine headaches, allergies, and left foot pain. The patient has requested authorization and coverage for acupuncture treatments. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether acupuncture treatments are medically necessary for the treatment of the patients medical condition. In this case, the patient reported acupuncture had been helpful for the treatment of her migraine headaches, allergies, and left foot pain. The medical evidence supports the requested services in this clinical setting. Therefore, acupuncture treatments are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in chiropractic care with expertise in acupuncture 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 reimbursement and prospective authorization and coverage for acupuncture services for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The documentation does not include a pre-acupuncture evaluation reporting the functional-motor-sensory deficits the patient had that needed to be addressed by an acupuncture trial. Ten acupuncture sessions were already completed without documentation of measurable, significant gains. Although the patient reported that acupuncture services had been beneficial, the records do not document sustained, significant, objective, functional improvement obtained with previous acupuncture. The medical evidence does not support the services at issue in this clinical setting. All told, acupuncture services were not and are not medically necessary 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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for T6, T7, and T8 thoracic radiofrequency ablation. Findings:  Three physician reviewers found that the records provided for review document physical findings on exam consistent with facet mediated pain. The provider noted diagnostic medial branch blocks resulted in greater than 75% improvement in pain for the duration of the anesthetic in support of radiofrequency ablation of the facet joint. Studies reported durable effect of radiofrequency ablation for lumbar facet syndrome at long-term follow-up, as measured by improvement in function, pain, and analgesic use. Studies noted good evidence for the use of conventional radiofrequency ablation, and fair to good evidence for lumbar facet joint nerve blocks for the treatment of chronic lumbar facet joint pain resulting in short- and long-term pain relief and functional improvement. Accordingly, the requested T6, T7, and T8 thoracic radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 52-year-old female enrollee has requested a 24-week course of Sovaldi (400 mg) and ribavirin (400 mg) combination therapy for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medications. According to the clinical documentation submitted for review, she is interferon ineligible and has a Metavir fibrosis score of about 2. In addition, she has evidence of active viral replication and no contraindication to treatment, such as hepatocellular carcinoma. Therefore, the request for 24 weeks of Sovaldi and ribavirin is medically necessary in this clinical setting. Based on the medical records submitted for review and the medical literature cited above, the request for a 24-week course of Sovaldi (400 mg) and ribavirin (400 mg) combination therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz. This patients alopecia areata has reportedly responded well to treatment with topical and oral corticosteroids with almost complete regrowth of hair. The current medical literature and guidelines recommend treatment with oral and intralesional corticosteroids, cyclosporine, methotrexate and JAK kinase inhibition, or squaric acid. Overall, the records document that this patient is doing well on their current regimen of intralesional and oral steroids. Thus, treatment with Xeljanz is not indicated. Given these findings, the requested Xeljanz is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication 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 dermatology 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.