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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The advantage of breast tomosynthesis relates to the ability to separate dense glandular elements from architectural distortion which in turn may indicate malignancy.  In this particular case where architectural distortion would have been inevitable due to lumpectomy and radiation therapy, this technique would have been of great advantage to the radiologist.  Hence, the addition of breast tomosynthesis was likely to be more beneficial to this patient than had the examination been done only with the two-dimensional technique. Final Result: Two reviewers determined that the services at issue were 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of the patient has requested authorization and coverage for Absorica (isotretinoin) 30 mg, two capsules twice daily. Acne vulgaris is the most common disease of the skin, affecting up to 80% of patients at some time in their lifetime. Acne vulgaris is a chronic condition with substantial negative psychological, social and emotional impacts. Females with facial acne typically respond more favorably to systemic antibiotic therapies than males. The combination of systemic antibiotics with topical therapies may show synergistic effects, thereby speeding up response and reducing duration of therapy. Absorica is a highly effective treatment option for moderate to severe acne, which acts by shrinking sebaceous glands. Absorica is appropriate for patients with acne resistant to other treatments, nodulocystic inflammatory acne, and acne fulminans. All told, the requested continued treatment with Absorica (isotretinoin) 30 mg, two capsules twice daily, 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pre-surgical electrical stimulation therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees scrotal pain.At issue in this case is whether the requested pre-surgical electrical stimulation therapy is medically necessary for treatment of the enrollees medical condition.It is unclear if the prosthesis is causing the patients symptoms. There is no evidence in the literature to suggest treatment of chronic scrotal pain with electrical stimulation therapy followed by prosthetic surgery is beneficial in alleviating symptoms. Therefore, electrical stimulation therapy would not be indicated and is not medically necessary.Final Result: The reviewer determined that the requested treatment 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) 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. Applying CALOCUS, a portion of the IOP services at issue were medically necessary for treatment of this patient. On the first day of the Health Plans denial, the patient has demonstrated significant risk of harm (score 3) due to a past suicide attempt and recent suicidal ideation with plan but without intent. The patient has exhibited moderate functional impairment (score 3) given her conflict with her family and recent gains made in the context of the IOP program. The patient has mild comorbidity (score 2) with a history of substance abuse and recent sobriety. The patients recovery environment has been mildly stressful (score 2) as she recently lost her aunt and has demonstrated distress over her parents performance expectations. The patients recovery environment is highly supportive (score 1) due to the presence of wraparound services as part of the IOP program. The patient has exhibited moderate response to treatment (score 3) with continued distress despite lower levels of care, and some recent progress at the current IOP including sobriety. The patient has been incompletely engaged in treatment (score 3). The records document that she has shown manipulative behaviors, continued conflict with her parents, and difficulty accepting responsibility for her actions. This gives the patient a composite score of 17, which is consistent with high intensity community based services, including IOP treatment. Per CALOCUS, minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has home speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that according to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, socialization, and behavior.  Specifically, speech sound disorder not only greatly reduces intelligibility, it has also been associated with later reading disability.  Speech sound disorders refer to any combination of difficulties that impact speech intelligibility, including perception, motor production, and phonological representation of speech sounds and segments.  Articulation disorders are those that impact the form of speech sounds and are associated with structural and motor-based problems.  Phonology disorders impact the way speech sounds function within a language. Treatment approaches have traditionally focused on either articulation or phonology.  Articulation approaches are typically selected if the problem is thought to be motor-based, and phonologic approaches tend to target specific sound error patterns.  The medical literature supports speech therapy intervention for young children with speech sound disorders.  This patient was receiving services through the school district prior to starting kindergarten.  The private school that he now attends has acknowledged his need for speech therapy, but is not able to provide it. Because of his family situation, he is unable to attend speech services outside of the home.  In the absence of school-based services and clinic based services, the means for this patient to receive the necessary intervention is through home-based services.  All told, the requested home speech therapy is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in pediatric critical care medicain 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 corneal collagen cross-linking. Collagen cross-linking has been approved by the U.S. Food and Drug Administration (FDA) for progressive keratoconus. The main criteria for treatment with collagen cross-linking is documentation of keratoconus progression. In this case, the records report progression of the keratoconus based on the topography from 2015 which showed an average keratometry of 45-46D to about 46-49D. Therefore, this patient has evidence of progressive keratoconus. Thus, the collagen cross-linking provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that given the limited randomized controlled clinical trials demonstrating the superiority of collagen cross-linking over standard available treatments for progressive keratoconus, the corneal collagen cross-linking provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue was 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:  One reviewer is board certified in ophthalmology and is actively practicing. One Reviewer is board certified in ophthalmology and is actively practicing.  One Reviewer is board certified in ophthalmology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male has requested coverage for past acute inpatient psychiatric hospitalization for treatment of his behavioral health issues.  Findings:  The physician reviewer found that applying the practice guidelines from the American Psychiatric Association (APA) and American Association of Community Psychiatrists (AACP), this patient no longer met the criteria for treatment at an inpatient level of care as of the date at issue. Based on a review of the patients records, on the date at issue,  he met the Milliman discharge criteria because he had had sufficient relief of the precipitants of his suicidal ideation, had an absence of thoughts or plans to harm himself or others, had no impairment in any essential function, and his medication management could be safely and adequately handled at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested for scanning laser ophthalmoscopy with retinal nerve fiber layer analysis for treatment of her eye condition. Findings:  Three physician reviewers found that there are no other glaucoma risk factors present.  Optic nerve status can be adequately and appropriately monitored with serial optic disc photographs.  The requested testing is not needed for this purpose.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested reimbursement for stab phlebectomy. The enrollee has a diagnosis of varicose veins in her left leg. This has caused pain, swelling, numbness, tingling, and stasis dermatitis. She tried compression stockings for a few years, but they did not help. She has tried over-the-counter anti-inflammatory medications that are helpful, but her symptoms return. The vascular surgeon determined the enrollee was a good candidate for excision of her varicose veins. A stab phlebectomy was performed. Local removal of varicose veins is the standard of care for those with symptomatic varicose veins, which are not responsive to conservative care with compression stockings, and which do not show axial reflux in the truncal veins. The stab phlebectomy was more beneficial than any other available standard treatments for this enrollee. Other procedures would have been inappropriate and inferior to this procedure.Final Result: The reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewers are board certified in vascular surgery and are actively practicing.  All 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient presented to labor and delivery on 6/23/17 at 25 weeks gestation with complaints of vaginal bleeding. An ultrasound showed a foreshortened cervix of 1.9 cm with old blood and mucus in the vaginal vault. The patient was admitted to the hospital. Irregular but frequent contractions were noted on tocometry that resolved shortly after admission. Fetal heart tones were reassuring and maternal vital signs were hemodynamically stable. The amniotic fluid index was 21 cm. Laboratory results showed mild iron deficiency anemia and a normal urinalysis. The patient was treated with magnesium and betamethasone. She continued to be monitored without acute issues and was given Procardia with subsequent discharge on 6/26/17. The patient has requested reimbursement for emergency medical services from 6/24/17 at 3:53 pm through 6/26/17. The Health Plan denied the request and reported the services at issue were not emergency medical services. At issue in this case is whether the services that were provided from 6/24/17 at 3:53 pm through 6/26/17 were emergency medical services. Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical manifests 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 placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The American College of Obstetrics and Gynecologists (ACOG) notes that a diagnosis of preterm labor is defined by the clinical criteria of regular uterine contractions and a change in cervical dilation, effacement, or both. The medical records reflect that this patient had uterine contractions but no evidence of cervical dilation despite serial examinations. Therefore, preterm labor was not present. Further, chorioamnionitis, fetal distress, maternal disease, and vaginal bleeding were not diagnosed. The patient had normal hemodynamics, and her fetus had category I fetal heart tracings. Tocolytic therapy was provided with magnesium for less than 24 hours. The patient was noted to be stable and without fetal distress or evidence of progressive cervical incompetence. Therefore, the services provided from  6/24/17 at 3:53 pm through 6/26/17 were not emergency medical services.Final Result: The reviewer determined the patient did not receive emergency medical services on the dates of service at issue. 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested in-home physical therapy for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that physical therapy is a mainstay of treatment for cerebral palsy.  Its focus on function and movement maximizes the patients potential.  In addition, physical therapy teaches patients ways to optimize their independence and self-help skills.  Physical therapy is part of a multifaceted approach, including medications and surgery.  Duration and intensity of therapy appear to be more important than the specific methodology used; often, use of multiple methods is necessary to provide the most effective treatment.  For those who are severely affected, comfort and ease of care are often the goals of therapy.  However, for adolescents, therapy should be geared toward establishing functional mobility and independence.  This patient requires physical therapy for prevention of contractures and facilitation of functional mobility and interaction with her environment.  Because of a preexisting medical condition, she is unable to participate in activities outside of the home without risk of infection; therapy outside of the home would provide unnecessary exposure and risk.  All told, the requested in-home physical therapy 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 pediatrics with sub-specialty certification in pediatric critical care 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

Nature of Statutory Criteria/Case Summary: A 50-year-old male enrollee has requested authorization and coverage for Opana 45 mg daily. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. In this case, the patient was recently taking 270 MME per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested Opana 45 mg per day is not supported as medically necessary for treatment of this patients chronic pain. 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 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 58-year-old female enrollee has requested inpatient psychiatric hospital services rendered at a dissociative identity disorder/trauma disorder unit and/or mental health therapy (2-3 times per week for 1.5 to 3 hours each) with a therapist that specializes in dissociative identity disorder, for treatment of the enrollees dissociative identity disorder, posttraumatic stress disorder, major depression, and borderline personality disorder.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) psychiatric textbook and the International Society for the Study of Trauma and Dissociation, psychotherapy is the primary vehicle for recovery and the most efficacious modality for treatment of dissociative identity disorder. However, the records do not support the medical necessity of the requested inpatient psychiatric hospital services rendered at a dissociative identity disorder/trauma disorder unit.  There is no evidence of an acute psychiatric syndrome or imminent danger to self or others that would warrant treatment at the inpatient level of care. Thus, based on the documentation provided, the requested inpatient psychiatric services are not medically necessary. Although the treatment team must carefully defend against a chaotic regression, with the assistance of a multidisciplinary treatment plan that clearly defines boundaries, goals and objectives, it is not uncommon to treat patients with dissociative identity disorder with multiple therapy sessions per week. Thus, two 90-minute sessions per week would be consistent with current practice standards. However, the Health Plans recommendation for an evaluation with a psychiatrist specializing in dissociative disorders to develop a treatment plan is reasonable to determine if the necessary services can be provided in-Plan. Based on the outcome of that evaluation, if the Health Plan did not have adequate specialty services or providers to address the patients medical needs, then the patient would have the opportunity for care from non-network specialists. Thus, until the Health Plans dissociative identity expert has had the opportunity to evaluate the patient, the outpatient therapy services as requested are not medically necessary. All told, the medical records have not demonstrated that the requested inpatient psychiatric hospital services rendered at a dissociative identity disorder/trauma disorder unit and/or mental health therapy (2-3 times per week for 1.5 to 3 hours each) with a therapist that specializes in dissociative identity disorder are medically necessary for treatment of this patients medical condition.