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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospital services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. Based on the documentation submitted for review, the patient received psychiatric emergency medical services during the dates of service at issue. On admission the patient was status post smoking heroin outside of the hospital and in active withdrawals. She verged on being considered gravely disabled, although she was not admitted on a 5150. She was using, concomitantly, heroin, methamphetamine, cocaine, benzodiazepines, and cannabis. She had not attended to her activities of daily living and was found in an unhygienic condition, with syringes in her purse. She had a serious overdose episode which could have ended calamitously. As such, this patient was unable to undergo detoxification in a less restrictive setting as she was unable to control her impulses long enough to gain insight and develop a modicum of coping mechanisms. In addition, her blood pressure fluctuated on numerous occasions. She remained anxious and depressed. She continued to suffer from daily withdrawals despite being on the Suboxone taper. Given her condition at admission, her past history of polysubstance use, multiple serious relapses and escalating use, the services at issue were necessary for treatment of a psychiatric emergency medical condition. Thus, the patient received psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient received psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of uterine artery embolization. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees uterine fibroids.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for lumbar spine magnetic resonance imaging (MRI). Findings: Given this patients age and presentation, conservative management is recommended. Surgical interventions should be reserved for use if the patients condition fails to improve with conventional measures.  The patients plain x-rays ruled out dramatic anatomic abnormalities. Although the patient has degenerative changes and short pedicles, in a young active patient who has a recent history of hurting their back after exerting themselves, MRI was unlikely to provide significant information that would change their plan of care. As has been shown in multiple studies, incidental findings of degenerative disease or disc abnormalities are common in asymptomatic patients. The American College of Radiology (ACR) has established criteria to help providers obtain efficient use of imaging modalities to evaluate various clinical presentations. Per the ACR, MRI is not usually appropriate in the management of chronic pain without other concerning signs or symptoms. On physical examination, the provider did not detect any abnormalities in strength, muscle tone, or reflexes. In addition, there is no evidence of tumor or infection. All told, the lumbar spine MRI  was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic 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

The patient is a 58-year-old male with a history of back pain. His history is significant for a motor vehicle accident in October 2003. He has been receiving physical therapy since at least 2002 and now is requesting authorization for continued therapy. The Health Plan has denied this request.The physical therapy records submitted demonstrate the patient has on-going complaints of neck, mid-back, and lower back pain. While documentation shows the patients pain and range of motion are sometimes better and sometimes worse, overall the patient had no improvement through 2003-2004. The physical therapy notes submitted provide no specific details regarding the treatments provided of why a home exercise program would not be appropriate for the patient. Furthermore, there is no overall plan of care or endpoint/specific goals for the patient. Nor does it appear there is a focus on discharge to a home program.Given the patients lack of progress and lack of evidence demonstrating why continued therapy is necessary, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denials should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. The patient was not in withdrawals.  He reported that his last use was approximately two weeks prior to admission.  He denied cravings. There was no evidence of danger to self or others. He was not psychotic or manic.  The documentation submitted did not note evidence of emotional, behavioral, cognitive, or impulsive symptoms that required supervision in a residential setting. Moreover, his medications did not require management at residential level of care. The patient was medically and psychiatrically stable. He could have been treated at intensive outpatient program or outpatient level of care.  Although initially he may have indicated that he did not feel he required treatment, he did participate in his treatment plan and endorsed motivation.  His parents were supportive and home environment was stable. The medical literature does not support residential treatment center level of care. For these reasons, residential treatment center services were 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 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

A 64-year-old female enrollee has requested Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  The physician reviewer found that Oncotype DX assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score that predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node negative, estrogen receptor positive tumors. It has become very important, particularly in this group of breast cancer patients in which it is very difficult to make recommendations about adding adjuvant chemotherapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services at a facility that treats children. Researchers found provided guidelines to help determine whether behavioral health services are medically necessary. Based on the presenting information, this patient does not meet the criteria for RTC placement at a facility that treats children. Specifically, the requested services are not required to meet the essential health needs of the patient, are not consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research, and is a more intensive setting than is appropriate for the delivery of health care. 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 a board certified BCBA, is board certified in psychology 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

A 49-year-old female enrollee has requested debulking surgery for treatment of her brain astrocytoma. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested surgery. Oligodendroglial tumors constitute between 5 and 20 percent of all glial tumors and typically present in the fourth to sixth decades, with low-grade tumors occurring at an earlier age than anaplastic tumors. Historically, the management of patients with anaplastic oligodendroglial tumors was based upon results from studies in patients with malignant gliomas, carried out prior to the recognition of the molecular and prognostic differences between oligodendroglial and other glial tumors. Compared with astrocytic tumors, oligodendroglial tumors are more likely to harbor certain favorable molecular markers, which are specifically relevant to treatment planning and prognosis.Surgery is utilized to relieve symptoms due to mass effect in patients with suspected anaplastic oligodendroglial tumors, with maximal resection being the preferred approach.  As in the current case, partial resection is required based upon the location and extent of the tumor. There is a lack of randomized trials that have established the benefit of maximal surgical resection compared with a more limited resection. In this case, the patient has received primary and secondary in-Plan neurosurgical opinions and both opinions suggest that the patient is not a surgical candidate and recommend hospice care. However, an out-of-Plan neurosurgeon has recommended surgical debulking based upon the patient's current exam, tumor type and prior history. Moreover, the out-of-Plan neurosurgeon has performed most of her neurosurgical procedures (with the exception of her initial craniotomy) and has been following the patient for many years. The medical records indicate surgical debulking would be in the patient's best interest and is medically necessary. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested the Acessa procedure that uses radiofrequency ablation for medical treatment of her uterine fibroids.   Findings:  Two physician reviewers found that Radiofrequency ablation is a type of myolysis and is a new alternative, with initial small studies that indicate that in appropriate patients it may become a reasonable surgical alternative.  Per the current medical literature on laparoscopic therapies for fibroids, the preferred approach is still laparoscopic myomectomy rather than myolysis.  This patient has indicated that preservation of her fertility is a goal, and many experts do not recommended myolysis for women who wish to preserve future fertility.  As there are a number of available standard treatments that have not been tried in this patient, the requested Acessa procedure that uses radiofrequency ablation is not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone/acetaminophen 10-325 mg, cyclobenzaprine 10 mg, and diazepam 10 mg for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that In the documentation available for review, the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative settings. However, in this patients case not all non opioid treatment options have been utilized. The medical literature suggests clinicians to consider alternative options to opioids as well as to wean patients to lower doses of opioids or even off opioids. Furthermore, the records do not mention a completion of physical and behavior therapy despite much research to support its use. Objective treatment goals for pain and function are not documented for the requested medications. The Centers for Disease Control and Prevention (CDC) states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established in this patients case. Finally, not all non opioid medication classes have been optimized or tried in this case. For all these reasons, the requested hydrocodone/acetaminophen 10-325 mg, cyclobenzaprine 10 mg, and diazepam 10 mg, are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 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 19-year-old male enrollee, with a six-year history of polysubstance abuse, has requested authorization for residential treatment services. Findings:  The physician reviewer found that there was no evidence of serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. There was no history of a rehabilitation attempt at a lower level of care prior to this admission. An intensive outpatient program along with a twelve-step program and a sober living arrangement would have been medically appropriate in lieu of the residential treatment admission.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a ten-month-old female enrollee has requested for a Dynamic Orthotic Cranioplasty (DOC) for treatment of the enrollees head shape.    Findings:  The physician reviewer found that the health outcomes of untreated plagiocephaly without synostosis are uncertain.  There are no randomized, controlled studies on the effects of this condition on neuropsychological function, development, the temporomandibular joint, or psychosocial concerns.  The natural history of this condition is not well documented.  Remarkably few adults have deformities of cranial symmetry or shape, suggesting that the abnormality is either self-correcting or effectively masked by a combination of increased cranial circumference and hair growth.  The available data do not support use of the DOC band.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested diabetic shoes for treatment of his diabetes. Findings:  The physician reviewer found that foot care is an essential part of diabetes care. It is standard of care to provide therapeutic diabetes shoes to patients with type II diabetes mellitus who are at risk for ulcers and amputations. However, in this patients case the submitted documentation does not include a foot exam to determine whether his feet have deformities that warrant extra-wide therapeutic or custom fitted shoes. Furthermore, there is no documentation that this patient is indeed at risk for ulcers or amputation. In summary, the submitted medical records do not support the contention that diabetic shoes are medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Per guidelines, genotype 1 patients who have failed Sovaldi/ribavirin therapy should be treated with Harvoni and ribavirin for 12 weeks. These guideline recommendations are based on multiple studies showing the effectiveness of Harvoni after Sovaldi failure (Osinusi, et al; Reddy, et al). AASLD guidelines cite data showing decreased survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  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 internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Kerydin 5% topical solution. The records provided for review document this patient has onychomycosis and dystrophic toenails.  According to the progress notes, the patient did not report pain or limitation of ambulation due to onychomycosis, nor does the progress note advise of painful ingrown toenails or paronychia. In the absence of pain or painful in-growing infected toenails, treatment with Kerydin for onychomycosis is not supported by the medical literature. This patients records do not document that the patient has achieved 48 weeks of treatment with ciclopirox. For these reasons, the requested Kerydin 5% topical solution is not medically necessary for the 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 a licensed D.P.M., 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 patient has requested authorization and coverage for topical tofacitinib. Tofacitinib has been shown to be effective in treatment of alopecia areata (AA). In a double-blind, placebo-controlled study concluded that topical Janus kinase (JAK) inhibitors could be developed as a potential new treatment for AA. In this case, the patient has tried and failed the standard treatment for focal AA. Other untried, non-standard therapeutic options are mostly systemic and may result in cumulative toxicities and other side effects. Based on the current medical literature, the requested medication is medically indicated. Therefore, topical tofacitinib 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 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

A 29-year-old female has requested a computed tomography (CT) scan of the chest/spine and CT of the lumbar spine for evaluation of her low back pain.  Findings:  The physician reviewer found that based on review of the available records, the patient has low back pain without any noted prior history of trauma or malignancy. The patients blood count is normal without signs of infection. There is no documented neurological deficit. The patient has not reportedly been treated with physical therapy. Due to a lack of concerning signs or symptoms such as radiculopathy, weakness, or abnormal neurological findings, and the lack of attempt at physical therapy, the requested CT scan is not medically necessary to evaluate this patients non-specific low back pain.