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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair with specifications noted, for treatment of her spinal muscular atrophy.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested power wheelchair with each of the requested specifications.  Spinal muscular atrophy is a disease without a cure that requires accommodation of functional impairments for treatment.  This patient has significant impairments and requires a power wheelchair to remain independent.  She requires each of the requested components for various reasons.  Power tilt and power recline are needed for pressure relief and repositioning.  Power seat height and anterior tilt are needed for independence with transfers.  She uses the power wheelchair in the community on uneven ground and also drives a motor vehicle from her power wheelchair, so the harness and hip belt are needed for safety.  A backrest frame is needed to accommodate a custom cushion that is appropriate for her pelvic obliquity and spinal deformities.  A swing away joystick and adjustable mount kit are needed for her to be able to transfer into and out of the wheelchair independently.  An expandable controller, seat function control kit, control module and compact joystick are needed for maneuvering the wheelchair and operating the seat functions of the wheelchair.  Group 24 gel cell batteries are needed to operate the power wheelchair and provide enough battery power to operate the wheelchair for the full duration of a day.  All told, the requested equipment is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center services and prospective future residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patients residential treatment was medically necessary for treatment of this patients behavioral health condition. The record also supports prospective services to treat the patients suicidal ideations. The notes reflect that the patient continued to entertain suicidal thoughts and was reported to make light of this behavior to his peers and was entertaining it readily. Studies show that one indicator of future completed suicide is the presence of prior suicide attempts.  For this case, the patient has a history of suicide attempts.  The notes reflect that the patient was openly talking about it with peers.  All told, residential treatment center services were medically necessary. Additionally, future residential treatment center services are also medically indicated for the treatment of this patients behavioral health condition.  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 sub-specialty 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 patient has requested authorization and coverage for bilateral mastectomies (CPT code 19303) and nipple reconstruction (CPT code 15200). Findings:  The physician reviewer found that The World Professional Association for Transgender Health (WPATH) Standards of Care acknowledges that some interventions have a radical and permanent effect on a patients quality of life, and therefore is more medically necessary than for someone without gender dysphoria. Olson-Kennedy and colleagues concluded that, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. The WPATH criteria for bilateral mastectomy and chest reconstruction is persistent, well-documented gender dysphoria, which is well documented in this patient. While this patient has a history of polysubstance use disorder, he has been in remission since November 2018 and chest surgery is likely to make a positive impact. The patients providers report that his mental health issues are well controlled and do not interfere with his ability to follow-up with his providers. Given these findings, the requested bilateral mastectomies (CPT code 19303) and nipple reconstruction (CPT code 15200) are medically necessary for 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 psychiatry with expertise in transgender 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for four months of residential treatment center (RTC) services, or any 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. Based on CALOCUS criteria, this patient meets the criteria for residential treatment. The patient has been at serious risk of harm to himself and others (score 4) as evidenced by significant impulsivity and physical aggression. The patient has shown poor judgment and insight and he endorses excessive substance use. The patient has demonstrated severe functional impairment (score 5) given his extreme deterioration in interactions with peers, adults, and family that include chaotic communication and assaultive behaviors with little or no provocation. The patient has significant comorbidities (score 3) due to a combination of depression, anxiety, and substance abuse. The patients recovery environment is mildly stressful (score 2) given his conflict with his mother. The patients recovery environment is supportive (score 2) as his mother has participated in treatment and treatment planning. The patient has shown negligible response to treatment (score 5) based on minimal response to past residential treatment. The patient has been non-collaborative (score 4) due to hostility and threats toward staff. The patient previously left the prior RTC without permission. This gives the patient a composite score of 25, which meets the criteria for medically monitored residence based services, such as RTC. However, due to scores of 5 on functional impairment and response to treatment, the patient meets the CALOCUS criteria for medically managed residence based services, such as inpatient psychiatric care, or a locked RTC program. Moreover, the patients providers at the prior RTC and patients current providers have recommended this level of care. Given patients resistance to treatment, dangerous behavior, and the failure to respond to a lower level of care, four months of RTC care in a locked facility that can manage patients who are at risk of leaving without permission is appropriate. Accordingly, four months of RTC services are medically necessary for 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for neurofeedback for treatment of the enrollees behavioral health issues. Findings:  Three physician reviewers found that there are limited studies regarding the efficacy of neurofeedback in the treatment of anxiety, insomnia, and attention deficit hyperactivity disorder (ADHD). Researchers found no difference between neurofeedback and placebo in subjective measures of sleep complaints. The authors concluded that based on this comprehensive and well-controlled study, we conclude that for the treatment of primary insomnia, neurofeedback does not have a specific efficacy beyond unspecific placebo effects. Importantly, we do not find an advantage of neurofeedback over placebo feedback, therefore it cannot be recommended as an alternative to cognitive behavioral therapy for insomnia, the current (non-pharmacological) standard-of-care treatment. Cognitive behavioral therapy (CBT) for insomnia is considered the gold standard non-pharmacological treatment. Overall, the records do not document that this patient participated in this non-pharmacological treatment or that he has exhausted standard medical therapies. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in psychiatry and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX prostate cancer assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.Findings:  National Comprehensive Cancer Network (NCCN) guidelines recommend testing with Oncotype DX post-biopsy for NCCN very-low- and low-risk prostate cancer in patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. Men with clinically localized disease may consider the use of tumor based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of death with conservative management, likelihood of biochemical progression after radical prostatectomy or external beam therapy, or the likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy.  Accordingly, this assay is considered a standard of care in guiding treatment decision making. Therefore, Oncotype DX prostate cancer assay was likely to have been more beneficial than any available standard therapy for the evaluation of this patients medical condition. Final Result: Two of the three reviewers have 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 internal medicine with sub-specialty certification in medical oncology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for minimally invasive decompression procedure. Findings:  The physician reviewer found that in the medical literature, a study performed a randomized controlled trial to evaluate the minimally invasive procedure percutaneous laser decompression versus conventional surgical techniques. The authors reported that there was no indication that the minimally invasive surgery was superior to open surgical techniques. This patient presents with a history of chronic lower back pain. He reported an onset of radicular symptoms in late last year. Clinical examination findings have not documented a focal neurologic deficit. There is imaging evidence of severe multilevel lumbar degenerative disc disease from L1-S1 and facet arthropathy from L1-L4. Conservative treatment has included facet blocks, epidural steroid injection and medications without sustained improvement. Additional conservative treatment has been recommended to include physical therapy. There is no compelling rationale presented to support the medical necessity of referral for laser surgery for this patients condition given the absence of evidence based medical literature support for laser surgery over traditional surgery. Therefore, this requested minimally invasive decompression procedure is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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

The parent of a five-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism. Findings:  Three physician reviewers found that the medical community has determined that OT is indicated for young patients with autism as evidenced by the American Academy of Neurology (AAN) practice guidelines. Specifically, the AAN recommends immediate and long-term evaluation and monitoring with a comprehensive multidisciplinary approach performed by a qualified experienced professional trained in the array of challenges associated with this condition. An OT evaluation should focus on gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped mannerisms, and the impact of these components on the autistic patients life. OT is indicated when deficits exist in functional skills in the areas of play or leisure, self-maintenance through ADLs, or productive school and work tasks. Sensory integration techniques are appropriate for patients such as this patient with deficits in sensory processing skills. Based on existing data including practice parameter guidelines accepted by the medical community, the requested OT services are likely to be of greater benefit for this patient than any standard alternative treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female with a history of obesity (55 and weighing 189 pounds with a body mass index of 31), and tendonitis. She has no documented history of diabetes, sleep apnea, hyperlipidemia, hypertension or arthritis. The patient has requested authorization and coverage for the medication Xenical. The Health Plan has denied this request indicating the requested medication is not medically necessary for treatment of the patients obesity.The Health Plans denial should be upheld. With a BMI of 31 and no significant comorbid conditions, the patient does not meet medical necessity criteria for Xenical. Additionally, there has been no submitted documentation indicating the patient has tried and failed lifestyle interventions such as diets, exercise programs, or behavior modification for weight control. Other treatment options including structured diet programs, nutritional counseling and physician supervised low calorie/exercise programs along with behavioral modification, would be medically appropriate prior to consideration of prescription pharmacotherapy. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for transcatheter pulmonary valve implantation, percutaneous approach, including presenting of valve delivery site when performed (33477). In this case, the patient has a native dilated right ventricular outflow tract and severe pulmonary regurgitation that requires replacement to prevent right ventricular failure and further life threating arrhythmias. As the patients right ventricular outflow tract is too big to allow successful placement of a percutaneous pulmonary valve, such as a Melody valve, the only other percutaneous approach is with use of a Harmony valve, which has been shown in current medical literature as successful in larger right ventricular outflow tracts. Given that additional open-heart surgery in this clinical setting of a severely dilated right ventricle and arrhythmias is associated with significantly increased risk of adverse cardiac outcomes compared to percutaneous valve placement, the use of a Harmony valve is the only viable percutaneous option. Therefore, transcatheter pulmonary valve implantation, percutaneous approach, including presenting of valve delivery site when performed (33477), is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested transcatheter pulmonary valve implantation, percutaneous approach, including presenting of valve delivery site when performed (33477), 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 service is 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested embolotherapy for treatment of her presumed pelvic congestion syndrome. Findings:  Two physician reviewers found that chronic pelvic pain is defined as non-cyclic pelvic pain of greater than six months duration, and this is a common presenting problem.  Pelvic congestion syndrome has been recognized as a cause of chronic pelvic pain, caused by retrograde flow down incompetent gonadal veins resulting in pelvic varicosities.  Embolotherapy is a widely available treatment tool that has become one of the primary means to treat pelvic congestion syndrome.  As noted by Kwon and colleagues, ovarian vein embolization is a safe and effective therapeutic method for the treatment of pelvic congestion syndrome.  Kim and colleagues followed patients for an average of 45 months and concluded that direct venographic evaluation with embolotherapy can achieve significant improvement in pain perception levels in patients with chronic pelvic pain caused by pelvic venous congestion.  All told, the medical literature supports the efficacy of the requested services in this clinical scenario.  In this patients case, embolotherapy is likely to be superior over all other treatment options.
Appeal type: Urgent Care
Decision: Overturned

A 41-year-old male enrollee has requested reimbursement for emergency services he received.  Findings:  The patient presented to the emergency department (ED) with a chief complaint of an increasingly severe sore throat with fever for the previous five days that had not been responsive to antibiotic therapy. The ED provider noted that it is very painful to swallow but the numerical level of pain was not recorded and the patient was not febrile. The patient reported that he was spitting in a cup because it was just too painful to swallow.  The physical examination revealed a red and edematous throat, more prominent on the right side. The patient was assessed with likely cellulitis without obvious abscess formation. The patient was given augmentin and prednisone in the ED and discharged with prescriptions for the same. He was instructed to follow-up with an otolaryngologist in two days.At issue in this case is whether a prudent layperson would have sought immediate medical attention in this case. 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.Cellulitis of the upper airway constitutes an emergency medical condition that requires immediate intervention with appropriate medications and timely referral to an otolaryngologist. The patients pain level and history of fever would have prompted a prudent layperson to seek care emergently. The patients decision to seek immediate medical attention is supported by the ED diagnosis, treatment regimen and follow-up instructions and is consistent with the response a prudent layperson would have had in this situation.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of hormone replacement therapy for the treatment of menopause.  The health plan denied the enrollees request indicating that the prescription medications are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medications are not medically necessary.