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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Northera for treatment of his medical condition Findings:  The physician reviewer found that Northera is a recently released medication to treat orthostatic hypotension, and neurogenic orthostatic hypotension. However, midodrine and fludrocortisone are also very effective agents for treatment of neurogenic orthostatic hypotension. There is a lack of evidence that Northera is more effective than midodrine or fludrocortisone. In sum, the medical necessity for Northera has not been established.  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 neurology 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 thirty-five year-old male with a high body mass index and multiple comorbidities is requesting authorization for Lap-Band surgery.  Reviewers Findings:The reviewing physician found that based upon the clinical information provided, the patient is a suitable candidate for Lap-Band surgery.  Also, Lap-Band surgery presents less risk than other bariatric procedures.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  This patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to pre-existing medical conditions, which can be exacerbated by ribavirin.  For these reasons, the requested Harvoni 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 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

The parent of a 16-year-old male enrollee has requested residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that on the date indicated, the patients psychotropic medication was increased.  The patient had a good visit home around the holidays. Thereafter, he had a successful programming trip to a designated location. On the date indicated, his disrespectfulness responded well to redirection. On the date indicated, he felt more confident and more empathetic with an improved ability to consider the perspectives of others and much greater control over his emotional state. His previous episodes of acting out were limited to conflict with rules.  However, he was responding to redirection. Moreover, there was no evidence of psychiatric instability or safety concerns.  There were no planned changes to his uncomplicated medication regimen. The patient was not able to describe any further growth he wanted to make before leaving the program. Finally, the treatment team has not provided information as to why continued residential programming is necessary as opposed to a comprehensive community-based programming consisting of partial hospitalization, in-home behavioral consultant services, applied behavioral analysis, dialectical behavior therapy, chemical dependency counseling, group therapy, family therapy, individual therapy and psychotropic medication management. In the absence of any additional documentation, the patient was suitable for transition to a less-restrictive treatment setting as of the date indicated. Based upon the documentation submitted for review and the peer-reviewed literature cited above, continued residential level of care treatment as of the date indicated was not and is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her breast cancer examination. Findings:  The physician reviewer found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of her hepatitis C virus. Findings: The physician reviewer found that according to the most recent 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment. For these reasons, treatment with Sovaldi and ribavirin  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

The parent of a 3-year-old male enrollee has requested speech therapy for the treatment of the enrollees autistic disorder. Findings:  The physician reviewer found that this nearly four-year-old patient has the classic features of autism. Psychometric testing has indicated severe communication dysfunction, but not severe intellectual impairment, which makes the patient a suitable candidate for speech therapy. Speech therapy notes report slow, but consistent improvement in language function. Failure to make rapid improvements would imply the need for more intensive therapy not discontinuing therapy. Speech therapy has been shown to provide its greatest benefit for autistic children under the age of five.
Appeal type: Urgent Care
Decision: Upheld

The parent of a four-year-old male enrollee has requested emergency services on an emergent basis for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in these circumstances would believe the patient was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patient had a history of right ear pain and cold symptoms for two days prior. The medical records noted a congested nonproductive cough. The patient was not toxic. He was well-appearing, well-nourished and in only mild discomfort according to the Emergency Department records. Vital signs and pulse oximetry were all normal on arrival. The patient did not have any concerning signs such as lethargy, vomiting, high grade fever, seizure activity or decreased responsiveness. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  Two physician reviewers found that there is a lack of support in the medical literature for the superior efficacy of the services at issue in this patients case. Several biomarkers have been developed to aid in the screening and diagnosis of prostate cancer. Such tests are often indicated in men with moderately elevated PSA or history of a prior negative biopsy. Their use facilitates reduction of unnecessary biopsies without sacrificing the early diagnosis of clinically significant prostate cancer. However, the utilization of this genetic testing for prostate cancer screening remains unclear. Further studies are needed before a recommendation can be made for its routine application in evaluating and identifying treatment options in patients diagnosed with prostate cancer. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 urology 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

The parent of a 15-year-old female enrollee has requested sub-acute residential psychiatric services for the treatment of the enrollees anxiety and attention deficit disorders.  Findings:  The physician reviewer found that the psychiatric services provided during the timeframe in question were not medically necessary at that level of care. At the time of the evaluation, the patient was not suicidal, homicidal, psychotic, or delusional and there is no documentation to support that there was any acute or imminent risk of harm to self or others. The suicide risk assessment clearly states this conclusion and the psychiatric evaluation performed also supports this conclusion. There is no documentation to support that the patient needed 24-hour supervision or monitoring. Evaluation of the patients suicidality, her diagnosis, medication management and academic testing could have been effectively and appropriately addressed at a less intense level of care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old female who is status post gastric bypass in 2003. Since the surgery she lost approximately 125 pounds. A result of this massive weight loss was excessive folds of hanging skin. To treat her excess tissue, the enrollee underwent a panniculectomy, thigh lift, and buttock lift in March 2005. The patient experienced skin rashes and pain because of her excess tissue. The Health Plan has provided coverage for the panniculectomy but has denied coverage for the thigh lift and buttock lift on the basis the procedures were not medically necessary.There is no evidence to support the medical necessity of the patients thigh lift and buttock lift. These procedures are rarely medically necessary. The patient had documented skin problems due to her excess abdominal skin, which should have resolved with the panniculectomy. The submitted documentation does not demonstrate a thigh lift and buttock lift were medically indicated to resolve functional impairments. For these reasons, I have determined the procedures at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old female diagnosed with attention deficit hyperactive disorder (ADHD) and Graves disease, previously treated with Ritalin SR 20mg twice daily.  She is specifically requesting Ritalin SR from her Health Plan, which has indicated it is not a formulary medication. The patient has contested the denial of Ritalin SR, indicating that because she felt stable and much more productive for the past six years with the Ritalin SR, she does not want her medication switched to the formulary medication, Metadate CD. In addition, she believes that her Graves disease poses an added risk and makes her particularly sensitive to side effects of various medications. Finally, she reports receiving medical advice to avoid generics and she notes failed prior trials of generic Ritalin and Cylert. The Health Plan believes there is no evidence that Metadate CD would be any less effective than Ritalin SR. Therefore, the Health Plan has denied authorization for Ritalin SR as not medically necessary.Though there may be no set evidence that one stimulant is necessarily more effective than another across a large populace of patients with ADHD, this does not detract from the evidence of differential benefit for any one patient. The submitted evidence documents the efficacy of Ritalin SR for this patient. The fact that the patient has been stable and productive for six years with Ritalin SR argues most favorably for continuing her medication as is. All told, I find that the requested medication, Ritalin SR, is medically necessary for treatment of the patients ADHD. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested authorization and coverage for a transrectal ultrasound (TRUS) with color Doppler and CAPRA score determination to enable his providers to formulate a more comprehensive treatment plan for the enrollee. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees prostate cancer.   Findings:  The physician reviewer found that this patient has a diagnosis of prostate cancer adenocarcinoma Gleason score of 7 (3+4) with one positive core of 7% involvement. The digital exam was normal and therefore his stage is T1c. A second ultrasound has been requested which is to include color Doppler. The medical literature shows that the color Doppler technique in this clinical setting has not been established to better diagnose tumor extension than the standard approach (Nelson, et al and Strigari, et al). The CAPRA score requires the age of the patient at diagnosis, PSA at diagnosis, Gleason score of the biopsy (primary/secondary), clinical score (T-stage), and percent of biopsy cores involved with cancer (May, et al). However, this patients record has the required information to calculate the CAPRA score. For these reasons, the requested prostate ultrasound with color Doppler has not been shown to be medically necessary in the management of this patients prostate cancer.
Appeal type: Urgent Care
Decision: Upheld

A 25-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson would have sought immediate medical attention a second time for a complaint of sore throat. A medical emergency is defined as the existence of a medical condition which exhibits symptoms of sufficient severity such that a prudent layperson would reasonably expect that serious impairment of bodily functions or serious dysfunction of any bodily organ or part would occur without immediate medical intervention. This patient had increased pain, but his pain level (5/10) was not severe. His fever was very mild. He was able to breathe, and he had no difficulty handling his own secretions. Furthermore, the patient did not require any parenteral medications. His vital signs did not demonstrate any tachycardia or tachypnea.  His condition was stable on his arrival to the hospital and remained so until his discharge, 34 minutes after he was triaged. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care in this setting to jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Magnetic Resonance Imaging (MRI) of the cervical spine and Magnetic Resonance Imaging (MRI) of the right wrist and elbow.American College of Radiology (ACR) Appropriateness Criteria for Chronic Cervical or Neck Pain indicate that magnetic resonance imaging (MRI) of the cervical spine is felt to be usually appropriate, and the addition of a radiculopathy is a further justifiable indication for cervical spine MRI. Often, it can be argued that in the clinical setting of an acute onset of pain or neurological signs it would be appropriate for a patient to first undergo a six week trial of conservative therapy such as physical therapy, strengthening exercises, and anti-inflammatory medications. The argument for delaying imaging studies for six weeks is more reasonable when a patient is only dealing with pain. In this case, however, the patient has developed objective, measurable neurological deficits (the ulnar neuropathy diagnosed by EMG) that reflect that the process is more chronic in nature. The patients development of muscle wasting is further supportive evidence that the process is chronic. Under these circumstances, the requested Magnetic Resonance Imaging (MRI) of the cervical spine is medically necessary to treat the patients medical condition.American College of Radiology (ACR) Appropriateness Criteria for Chronic Wrist Pain also reflect that MRI is usually appropriate for chronic wrist pain on the ulnar side. The ulnar nerve can become entrapped at several levels, the most common at the elbow and wrist. While conservative therapy is most commonly utilized, there are various surgeries designed to free the entrapment. As such, it is necessary to better direct the surgery with imaging modalities. Researchers have stated that in certain cases, a preoperative evaluation of the exact lesion localization would be a valuable benefit for the surgeon. Researchers noted that there are several studies arguing that T2-weighted MR neurography is a highly accurate tool to identify, localize, and quantify ulnar nerve damage in patients with ulnar nerve entrapment. In this case, considering the severity of the patients symptoms and the apparent chronicity (based on muscle wasting), the MRI of the right wrist and elbow are reasonable and will help to clarify therapeutic options including possible surgery. Accordingly, the requested Magnetic Resonance Imaging (MRI) of the right wrist and elbow is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) level of treatment, three days a week. The American Psychiatric Association (APA) guidelines for patients with major depressive disorder notes that admission to an intensive day program, may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. This patients records document that she has a severe illness with complicating psychiatric conditions. In addition, the patients condition has not responded adequately to outpatient treatment. The provider reports the patient has demonstrated improvement in her condition, which supports IOP level of care as the appropriate modality for her but improvement. However, the patient remains at risk to herself in terms of suicidal thoughts and self-neglect. Thus, her improvement is only partial and requires consolidation. Continued treatment at IOP level is consistent with standards of good medical practice and the APA treatment guidelines. Thus, the IOP level of treatment, three days a week were and are medically necessary for treatment of this patients behavioral health issues. 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 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.