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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation supports the medical necessity of the services at issue. This patients polysubstance use was complicated by co-occurring depression and anxiety. His substance use and psychiatric symptoms were impairing his daily routine and negatively impacting his occupational and interpersonal domains. He had only fair motivation. Finally, he had been treated at various levels of care, but had been unable to maintain sobriety. During the disputed timeframe, the patient was engaged in active treatment. However, he remained symptomatic. He endorsed daily craving and no motivation. He was still craving substances. He worried about relapsing. His sleep was disrupted by nightmares. His antidepressant was changed, and his anti-craving medication was increased. Considering the severity of this patients illness burden and his past treatment failures, the partial hospital program level of care was safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided were reasonably expected to improve his condition and prevent a more serious episode of illness. All told, partial hospitalization program services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested podiatry consultation with Hermoz Ayvazian, DPM for wart removal for treatment of the enrollees plantar wart.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  The records document warts to the plantar aspect of the left foot.  In his application for independent medical review, the patient reported that the warts are extremely painful and are inhibiting his normal comfortable ambulation.  The patient also reported that he has had these warts in the past.  The current medical evidence supports the requested services in this patients case.  All told, the requested podiatry consultation for wart removal is medically indicated 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 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

The representative of a 14-year-old female enrollee has requested psychiatric residential treatment services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the patient has a concerning history of drug use, anxiety and mood symptoms with recurrent suicidality, coupled with limited coping skills and poor psychological mindedness. The patient also lacks an internal locus of control, healthy sense of self and the ability to self-soothe. These limitations are compromising her developmental task of identity formation. Per the medical records, the patient has failed outpatient treatment and required multiple acute care services. Currently, she remains symptomatic with anxiety, poor impulse control, and urges to use drugs. Her family dynamics and home situation remain volatile. She is described as active in therapy, recently beginning trauma focused therapy, but the patient has not consolidated the treatment gains necessary to succeed in a less restrictive setting. The patients affective dysregulation, anxiety, urge to use, psychosocial stressors, family support system and developmental factors unique to her case would likely undermine efforts at a lower level of care at this time. Consistent with these findings, the residential treatment to this patient is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the lumbar spine and pelvis (procedure codes 72148 and 72195). The Health Plan denied the request and reported the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were medically necessary for the evaluation of the patients medical condition. The American College of Radiology appropriateness criteria indicates that MRI of the lumbar spine is usually not appropriate for acute, subacute, or chronic uncomplicated low back or radiculopathy without red flags or prior management. In this case, there was no documentation of any red flags, such as neurological compromise. There was no indication of how many physical therapy sessions the patient had or the results of those sessions. There was also no documentation of a repeat ultrasound of the left ovary indicating a need for an immediate pelvic MRI. The clinical presentation of left sciatica does not support the medical necessity of a pelvic MRI. Therefore, MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services 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 radiology 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 focal cryoablation surgery provided by an out-of-network provider for treatment of his prostate cancer. The physician reviewer found that cryosurgery is a thermal therapy involving freezing tissues to subzero temperatures leading to cold injury. Cryosurgery has been commonly utilized for treatment of prostate cancer.  Recent technological advances have allowed for the procedure to be done on an outpatient basis with 5-14 days of catheterization. The most common form of cryotherapy is total gland ablation, whereby the whole prostate gland is ablated. This is similar to other prostate cancer treatments such as radiation and surgery which involve treating the whole prostate gland. The National Comprehensive Cancer Network (NCCN) guidelines state that cryosurgery is a treatment option following failure of radiation therapy. It is not recommended as an initial treatment at this time. More research is needed to compare cryosurgery to prostatectomy and radiation therapy. This patient has intermediate risk prostate cancer with possible extracapsular extension on MRI. He has documented bilateral disease based on biopsies. He was offered radiation therapy (brachytherapy and external beam) and radical prostatectomy, both of which are widely accepted standards of care for treatment of localized prostate cancer. Based on the available clinical documentation and medical literature, focal cryotherapy would not be best option for long-term treatment of this patients prostate cancer. Thus, focal cryoablation surgery provided by an out-of-network provider was not medically necessary for treatment of this patients medical condition. 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 urology 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 55-year-old female enrollee has requested a Magnetic Resonance Imaging (MRI) of the breast for the evaluation of her medical condition. Findings:  The physician reviewer found that if indeed there was a palpable abnormality on physical exam, the MRI would not have settled the issue as to whether biopsy was indicated or not.  MRIs are not always positive when a malignancy is present, and they may also yield false positive results as well.  In this patient, an ultrasound would have been indicated.  If there was a cyst or some other clearly benign finding, a biopsy would be avoided.  However, in a patient such as this (where malignancy is obviously of concern), biopsy of a palpable mass, particularly if there is a change noted on physical exam, would have been indicated no matter what the scans may have shown, absent a cyst shown on ultrasound.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Synvisc injections. The submitted documentation supports that the requested services are medically necessary. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Synvisc injections are medically necessary to treat the patients medical condition at this time.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa knee injections for treatment of the enrollees osteoarthritis of the left knee. Findings:  The physician reviewer found that Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  The American Medical Society for Sports Medicine recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this case, the patient presents with severe left knee pain with associated crepitance and limited motion. She reports functional difficulty in walking. Clinical examination findings are consistent with reported radiographic evidence of the left knee osteoarthritis. She has failed to improve with at least three months of conservative treatment, including activity modification, nonsteroidal anti-inflammatory drugs, and a corticosteroid injection. Therefore, the request for Euflexxa injections for the left knee are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services 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 orthopedic 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

A 41-year-old female enrollee has requested for the use of robotic assistance during myomectomy for treatment of her uterine fibroids.  Findings:  Three physician reviewers found that Laparoscopic myomectomy is a treatment option for some women with symptomatic fibroids as it minimizes the size of the abdominal incision and oftentimes results in a shorter post-operative recovery. However, currently there are no peer-reviewed randomized controlled studies comparing the addition of robotic assistance to laparoscopic myomectomy. Further studies, including randomized clinical trials, are needed to better determine clinical outcomes as the proposed procedure is still considered experimental and investigational.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying CALOCUS guidelines, this patient meets the criteria for mental health RTC services. This gives the patient a composite score which is consistent with high intensity community based treatment. However, due to the patients score on risk of harm, the recommended level of care is Level Five, medically monitored residence based services. Furthermore, the patient qualifies for Level 5B, intermediate stay medically monitored residence based services given his impulsivity, co-occurring substance use and mental health disorders, and lack of response to lower levels of care. Per CALOCUS, the length of stay at this level of care is up to 60 days. Given these findings, the mental health RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: Urgent Care
Decision: Upheld

A 19-year-old male enrollee has requested reimbursement for emergency services.  Findings:  The physician reviewer found that the patient presented to the Emergency Department (ED) in the morning of the date in question with a chief complaint of awakening with congestion in his right ear.  The pain level was documented by the triage nurse to be 5 out of 10 or moderate pain.  The treating physician noted that the patient was non-toxic and afebrile and that the right tympanic membrane is red and dull.  No treatment was rendered in the ED.  The diagnosis was right otitis media and the patient was prescribed azithromycin (an antibiotic) and Vicodin (an opioid pain medication).  He was discharged from the ED with follow-up instructions to see his primary care physician if he did not improve within three days.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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. The patient was noted to be non-toxic looking and afebrile in the ED. In this case, the patients pain level was documented by the triage nurse to be only moderate, which is a determinative factor.  Given the absence of a severe level of pain as well as any other acute symptoms such as fever or significant swelling, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention in an emergency room. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral sacroiliac radiofrequency ablation. King and colleagues report that the literature on sacral lateral branch interventions is sparse. The authors found that one study demonstrated the face validity of multisite, multidepth sacral lateral branch blocks for the treatment of posterior sacroiliac complex pain, and some evidence of moderate quality on therapeutic procedures, but concluded that there was insufficient evidence to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy. In this case, the patient has sacroiliac joint dysfunction and sacroiliitis and reported axial low back pain radiating to the buttocks without radicular pain down to his legs. He rated his pain at an eight out of ten and noted that it was alleviated by laying down, sitting and injection therapy. The patient reported that previous bilateral sacroiliac blocks provided 75% to 80% relief, with visual analog scale (VAS) decreasing to three out of ten for six hours following the diagnostic block. Given the limited published peer reviewed literature on the safety and efficacy of the requested service in this clinical setting, the requested service is not medically indicated. Therefore, bilateral sacroiliac radiofrequency ablation is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Oasis Wound Matrix. This patient has a diabetic foot ulcer. He has experienced poor progress in the healing of his wound with standard therapy including serial debridement, wound care, and off-loading. According to the medical records provided, there has been evidence of progress in the healing of his wound with the use of the Oasis Wound Matrix. The literature supports the use of wound matrices for the healing of poorly healing diabetic foot ulcers. Oasis is a product that has been demonstrated to show a benefit in the healing of wounds in this clinical setting. Therefore, the Oasis Wound Matrix was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Findings:  Two of the three physician reviewers found the Oasis Wound Matrix was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were 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 plastic surgery 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 19-year-old male enrollee has requested psychiatric residential treatment center services for the treatment of his behavioral health issues. Findings:  The physician reviewer found that this patients discharge summary from the prior admission confirmed continued problems with depressed mood, poor coping skills, and irritability. The psychological evaluation completed also reports prominent symptoms of depression. Given the patients significant history of mood disturbance, substance use disorder, history of overdose, previous acute psychiatric hospitalization, non-compliance with outpatient treatment, and continued significant functional impairment, the services provided were medically necessary. This patient was non-compliant with previous treatment and clearly exhibited suicidal thoughts requiring one-to-one supervision and management. The services of a 24-hour subacute residential treatment facility were clinically indicated for this patient. Additionally, the level of care provided to this patient was consistent with the American Psychiatric Association (APA) practice guidelines and Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) guidelines.