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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and coverage for intensive outpatient program (IOP) services received. 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, treaters 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) medical, addictive 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.Regarding the six CALOCUS dimensions, the patient has a low risk of harm; he has not expressed any suicidal or homicidal ideation or intent (score = 1). Regarding functional status, the patient displays no limitation in the performance of activities of daily living (score = 2). There are no comorbidities noted (score = 1). The patients home environment appears to be moderately stressful (score = 2) and the patient has limited support at home (score = 3). The patient has also been responsive to treatment interventions (score = 1), has been active in and accepting of treatment (score = 2) with moderate acceptance/engagement from family (score = 3). For a CALOCUS composite score of 15, the recommended level of care is low-intensity outpatient therapy. Therefore, the IOP services provided were not and are not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy provided over a seven-month period. The Health Plan has denied this request indicating that the therapy at issue was considered investigational for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient has a greater than 20 year history of depression. His psychiatric diagnosis was noted to be major depressive disorder.  His symptom complex consisted of depressed feelings, anhedonia, cognitive impairment, interpersonal withdrawal, weight change, fatigue, and diminished occupational performance. In the clinical documentation provided, the patient was noted to have pursued psychotherapy, however, there is no mention of electroconvulsive therapy or inpatient psychiatric care, residential programming or partial hospitalization. The patient has reportedly trialed multiple psychotropic medications including sertraline, escitalopram, fluoxetine, paroxetine, bupropion, duloxetine, desvenlafaxine, nefazodone, aripiprazole and lamotrigine. Psychopharmacotherapy had not achieved remission. Due to persistent symptomatologies, transcranial magnetic stimulation (TMS) therapy was recommended and the patient received TMS from for seven months.  The patient is requesting reimbursement for the TMS therapy which has been denied by the Health Plan on the basis that it is considered investigational.  Although this fairly new treatment technology lacks a robust heterogeneous evidence base at this early stage of implementation, the literature supporting TMS in terms of volume, quality and range of investigation continues to grow.  The work from Gross, et al. and Schutter suggest that the efficacy of TMS is greater than originally reported, while researchers such as George, et al. and Demitrack, et al. are reporting more conclusive findings in well-developed studies. Additionally, the Food and Drug Administration (FDA) has approved TMS for the treatment of depression. The American Psychiatric Association (APA) has also endorsed the use of TMS for the treatment of depression during the acute treatment phase. Therefore, TMS is indicated for the treatment of acute phase unilateral depression. However, the peer-reviewed medical literature has not demonstrated the effectiveness of ongoing, long-term treatment with TMS therapy. Additionally, the documentation provided in this patients case did not include a psychiatric assessment detailing the patients diagnosis, current functional status, medication history, therapy history or the rationale for providing TMS therapy. Further, there is not a detailed description of any evidence based psychotherapy trials or well-established medication management with augmentative strategies that are commonly used in the treatment of major depressive disorder. Therefore, the TMS therapy provided during the timeframe in questiion was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested weekly marriage counseling for treatment of his relationship issues. Findings:  The physician reviewer found that the documentation indicates that the patient has been separated from his spouse.  The medical notes indicate that his spouse has reported that she wants a divorce. Furthermore, the couple is receiving counseling through their place of worship. Given that the spouse does not appear motivated, marital therapy is unlikely to be successful.  Additionally, this would be redundant to the services that they are already receiving. The data reviewed fail to establish that the requested weekly marriage counseling is necessary or would likely have a successful outcome. The submitted documentation does not establish that weekly marital therapy is indicated at the present time according to current-evidence based practice standards and expert consensus. The Health Plan has authorized coverage for marriage counseling at a frequency less than weekly.  The submitted documentation does not demonstrate that marriage counseling at a frequency greater than the authorized frequency is medically indicated.  All told, the requested weekly marriage counseling is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400/100 for eight weeks for treatment of the enrollees hepatitis C virus.Findings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa for 12 weeks is recommended as first line therapy for treatment naive, genotype 2 patients. This recommendation is based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. However, eight weeks of therapy, as requested in this case, is not recommended.  For these reasons, the request for Epclusa for eight weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees chronic hepatitis C virus genotype 3.  Findings: The physician reviewer found that according to 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 regardless of fibrosis stage should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Although, a possible enlarged lymph node was seen on ultrasound, there is no established medical condition in this case that limits life expectancy to less than one year. This patient should be considered treatment-naive because although she took a partial course of interferon, she did not fail a course of peg-interferon and ribavirin due to nonresponse or relapse. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is the recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population (Nelson, et al). Further, delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested Sovaldi with Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for knee surgery at a facility with a pediatric cardiac transplant program/team.The current medical evidence supports subchondral drilling in the knee for small to mid-sized lesions. Surgical indications include conservative treatment for a minimum of two months and joint pain and swelling. Objective clinical findings which are required include full thickness chondral defect on the weight-bearing portion of the medial or lateral femoral condyle, stable knee with intact and fully functional menisci and ligaments, normal knee alignment and normal joint space. A study concluded that although multiple drilling is a safe and minimally invasive surgery, its effect is limited, particularly in solid organ transplantation patients with osteonecrosis of the femoral head (ONFH) due to long-term corticosteroid use. Thus, solid organ transplantation patients should be closely monitored in terms of ONFH development. This patient presents with a complex cardiac history with bilateral knee pain. He is status post heart transplant and developed bilateral knee avascular necrosis due to prolonged steroid use. His provider has recommended subchondral drilling to attempt to delay major reconstructive surgery. There is sufficient support for the requested services in this setting. This patient has open growth plates, which further supports the less invasive treatment. Additionally, it is medically necessary that the patient undergo surgery at a facility with a pediatric cardiac transplant program/team. Potential perioperative issues would be optimally addressable by cardiac providers already cognizant of the patients prior ongoing cardiopulmonary status, which may be labile. Therefore, the requested knee surgery at a facility with a pediatric cardiac transplant program/team is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for spine surgery on the neck.Findings:  Two of the three physician reviewers found that the medical evidence supports the requested services in this clinical setting. There are significant benefits documented in the literature with respect to total disc replacement which results in improved general and disease-specific outcome measures and a lower rate of reoperation in the two-level disc replacement patients versus two-level anterior cervical discectomy and fusion control patients.  With regards to the long-term results of cervical total disc replacement, there are significant benefits over the conventional multilevel anterior cervical discectomy and fusion. There is motion preservation, decreased incidence of adjacent segment disease, improved clinical outcome and decreased need for revision surgery. The requested services are likely to be more beneficial for treatment of this patient than the standard two-level anterior cervical discectomy and fusion. Thus, the requested spine surgery on the neck  is likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested services are likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy. The Health Plans denial is overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic 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: Upheld

A 38-year-old female enrollee has requested for a cervical MRI, MRI of the shoulder, and refills of the medication Vicodin for treatment of her neck and shoulder pain. Findings:  The physician reviewer found that the usefulness of repeated magnetic resonance imaging (MRI) studies is limited to particular situations. One indication for repeat MRI is significant changes in clinical findings. Additionally, repeat MRI may be indicated before a proposed surgery to evaluate the anatomical status of the involved region (see Benz and colleagues). Further, in the case of a patient suffering from multiple injuries in the same physical region with a prolonged time period in between the injuries, an MRI may be indicated to reassess the status of the structures involved. In the absence of factors such as these, there is little evidence of the value of repeated studies (see Mays and colleagues). The medical records in this case document that this patient received an adequate evaluation at each of her provider visits, and there is no evidence of the presence of any examination findings supporting the need for additional MRI studies at this time to evaluate her cervical spine or right shoulder.In this patients case, the submitted clinical evidence suggests possible dependence on Vicodin, and the patient has been referred to a chemical dependency rehabilitation program. There is no indication in the patients record to support the continuation of her narcotic prescription (Vicodin).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of scar tissue in the intestine for treatment of the enrollees incisional post-operative pain status post total abdominal hysterectomy.  Findings:  The physician reviewer found that Based on the available documentation and current medical literature there is a lack of evidence that takedown of the adhesions will improve this patients abdominal pain. There is a paucity of data suggesting that abdominal scar tissue would cause this patients recurrent infections. Performing a scar tissue takedown will likely be more damaging than beneficial for the patient and will have the outcome of worsening the scar tissue and adhesions. Thus, the requested removal of scar tissue in the intestine is not supported as medically necessary for treatment of this 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 thoracic 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: Upheld

The parent of a 13-year-old male enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on review of the available records, although this patients pre-treatment height was 2.5 standard deviations (SDs) below normal for age and gender, there is no clear documentation of poor linear growth velocity or low pre-treatment growth factors. In addition, provocative GH testing revealed normal results. Thus, this patient does not meet standard criteria for GH deficiency. According to the recent Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity in less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet most of these criteria based on the information provided. Furthermore, given the arrest in weight gain that is notable on review of the patients growth chart, documentation that the patient has a normal erythrocyte sedimentation rate (ESR) and celiac antibody panel is warranted to rule out other causes of growth failure prior to consideration of GH therapy for this patient.Without documentation to support low pre-treatment growth factors, poor pre-treatment linear growth velocity, and laboratory testing to rule out occult systemic causes of poor growth, the requested GH therapy has not been established as medically necessary in the management of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a biopsy. Findings:  The physician reviewer found that, at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the 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. The biopsy performed was not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient presented with ductal carcinoma of the breast. Breast cancer is often slow growing and the goal for surgery or chemotherapy is within 30 days of diagnosis. Many breast cancer patients are seen within a week of diagnosis to decrease fear and anxiety not for risk of harm to limb or life. Therefore, the service at issue was not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility services provided. Findings:  The physician reviewer found that the patient had a baseline of being non-ambulatory for many years. Although the medical literature generally supports subacute or skilled nursing facility level inpatient rehabilitation in a variety of clinical settings including cardiomyopathy, the medical literature does not support the necessity of this intervention indefinitely in the absence of expected functional progress.  Moreover, the documentation does not indicate that the patient has any other ongoing skilled nursing or medical needs requiring inpatient hospital level care.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

A forty-nine year-old male with chronic back pain is requesting reimbursement for an MRI.Reviewers Findings:The reviewing physician found that the patient underwent an orthopedic spine consultation in which the MRI study was a vital element utilized in determining that the patient may require surgery.  The reviewing physician found that the Health Plan denial should be overturned.