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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for Intensive Outpatient Program (IOP) Services. The enrollee has diagnoses of major depressive disorder, recurrent episode, severe; generalized anxiety disorder, and seizure disorder. The enrollee has diagnoses of major depressive disorder, recurrent episode, severe; generalized anxiety disorder and seizure disorder. She attended the IOP and was discharged to an outpatient level of care, which she attended for about two months. However, she was readmitted to the same IOP due to increased anxiety and depression. Admission documentation describes her as depressed, irritable and impulsive, with poor self-care. Documentation also notes passive suicidal ideation.  Discharge summary notes indicate towards the end of her stay, the enrollees participation and engagement in groups was variable. She was generally calm in groups, but had low frustration tolerance and would leave if she became upset. No self-harming behaviors were noted. Child and Adolescent Level of Care Utilization System (CALOCUS) applied in this case  The enrollees composite CALOCUS score is 16, which correlates with low intensity, community-based services.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested for real-time cardiac monitoring for evaluation of his medical condition.   Findings:  Three physician reviewers found that the use of remote real-time cardiac monitoring for the detection and precise characterization of arrhythmias, and its utility in guiding therapy is being increasingly recognized as having value (see Israel). The technical capabilities of its methodologies are no longer in question, and in most cardiac centers it is no longer considered an investigational tool as its value is supported by the medical literature. In one example, a study by Rothman and colleagues concluded that real-time event monitoring was superior in confirming the diagnosis of clinically significant arrhythmias, detecting such events in 55 of 134 patients (41%) compared with 19 of 132 patients (15%) in the patient-activated, standard event monitor group. This study confirmed, in a multi-center and prospective fashion, that real-time cardiac monitoring provided a significantly higher yield than standard cardiac loop recorders in patients with symptoms suggestive of a significant cardiac arrhythmia.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested Lyrica for treatment of her fibromyalgia. Findings:  The physician reviewer found that in the medical literature, Wilson and colleagues reported that fibromyalgia is a heterogeneous condition, however, the consensus is that tender points may be a symptom of the condition. In fact, the authors suggest that the severity of tender points may also help determine a patients response to therapy. For management of this condition, Shneker and McAuley concluded that Lyrica is a highly effective medication for a wide variety of conditions including fibromyalgia. This patients records provide inadequate documentation of clinical signs and symptoms of fibromyalgia consistent with the guidelines set forth by the American College of Rheumatology. Further, the providers notes fail to indicate the existence of tender points and aside from the patients current treatment regimen, there was no indication of the prior medications given and the patients response. Thus, requested Lyrica has not been proven to be medically necessary for this patient since a diagnosis of fibromyalgia has not been demonstrated in the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for transcranial magnetic stimulation therapy for treatment of the her major depressive disorder. Findings:  The physician reviewer found that the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  There is sufficient evidence in peer-reviewed medical literature to support the use of transcranial magnetic stimulation.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a consultation for breast reduction surgery for the treatment of her thoracic and cervical spine pain. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the patient is seeking a procedure that is reconstructive in nature. Breast reduction surgery removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion with a patients body and to alleviate discomfort associated with excessively large breasts. Although this patient has large breasts, given her body mass index (BMI) of 41, her breast size is not overtly large. Nor is there evidence of breast asymmetry or disease or infection affecting the breast tissue. As such, the patients condition is not considered an abnormal structure of the body. Therefore, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. With regard to general concepts of medical necessity, the patient has complaints of thoracic and cervical spine pain. She is morbidly obese, has fibromyalgia and had MRI evidence of cervical disc disease. Given her multiple comorbidities, it is not clear that her breasts are the source of her musculoskeletal symptoms. She is said to have frequent infections, but there is only one primary care physician note that describes breast fold infections. A plastic surgery consultation is not medically necessary as it is not documented that the patient's neck and thoracic pain are secondary to the size of her breasts. She has fibromyalgia and cervical disc disease as the possible etiologies for her symptoms. Based upon the size of her breasts in the photographs, those diagnoses appear to be the more likely cause(s) of her pain than her breast size. There is no evidence that she has tried and failed standard treatments for those diagnoses, including weight loss and physical therapy, to assess the response of her symptoms to those more conservative measures.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female has requested approval for past magnetic resonance imaging (MRI) of the breast for evaluation of her heterogeneously dense breast tissue with multiple cystic lesions.   Findings:  Three physician reviewers found that the patient has a family history of postmenopausal breast cancer. No positive physical findings. The patients mammogram and ultrasound reports have been very equivocal. This has led to MRI evaluation of the breasts where the report was also equivocal and recommendation was made for short-term follow-up with MRI due to abnormal enhancement within several areas. A repeat or follow-up MRI was requested and denied by the Health Plan as being investigational since there is no evidence of increased risk of breast cancer. Conventional imaging including mammography and targeted ultrasound have been equivocal in this patient therefore her provider recommended further evaluation with MRI, which was done. This examination showed some abnormal findings including enhancement patterns that can only be followed with MRI. Since an abnormal MRI was documented in the records, a repeat MRI was the appropriate imaging modality for accurate change, especially considering the enhancement findings. Repeat targeted ultrasound would not provide such analysis. MRI in this instance is the standard of care.  All told, MRI is the most sensitive means for early detection of breast cancer in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for excess skin removal (15832 RT and LT; excision of excessive skin and subcutaneous tissue of the thigh). Based on review of the records and photographs provided for review, the requested services do not meet the criteria for medical necessity. The patient is still obese by BMI criteria. The patient complains of functional issues, but there is a lack of documentation of functional limitations from the provider. Moreover, the records do not report that the patient has failed adequate treatment of her rashes with creams, including antibacterial or antifungal therapies. The American Society of Plastic Surgeons (ASPS) states that medial thigh lift is a procedure that treats the excessive skin and fat of the medial thigh and may include liposuction. The ASPS noted that severe excessive skin in the medial thigh region is required to be considered a functional abnormality. Thus, the requested excess skin removal (15832 RT and LT; excision of excessive skin and subcutaneous tissue of the thigh) is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. This patients condition does not constitute an abnormal structure of the body. There is a lack of documentation to support the presence of functional disability. In addition, the records do not describe failure of conservative therapy to address a functional disability. Moreover, the requested surgery would not provide more than a minimal improvement in the appearance of the patient. All told, the requested excess skin removal (15832 RT and LT; excision of excessive skin and subcutaneous tissue of the thigh) is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks for treatment of the enrollees 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 (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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. The guidelines recommend several medications, but Epclusa is the most appropriate therapy in this case based on NS5A resistance testing. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewers determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer number is a 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 enrollee is requesting authorization and coverage for a cervical spine magnetic resonance imaging (MRI). The enrollee has cervical degenerative disc disease (DDD), upper back pain, pain in the left shoulder, and cervical spinal stenosis. He has a history of radiofrequency ablation on multiple levels. A magnetic resonance imaging (MRI) scan several years ago showed evidence of spinal stenosis, questionable myelopathy of the cervical spine at the C3/C4 and the C6/C7 level; and degenerative disc disease (DDD) at the C5/C6 level. A visit note indicates the enrollee was seen for chronic neck and base of skull pain. He also has left shoulder pain. On examination, strength was 5/5 to the upper and lower extremities.  There were no sensory deficits to light touch, pinprick or vibration.  Deep tendon reflexes were 2+.  The treatment plan included an MRI of the cervical spine.  Review of the medical literature indicates an MRI of the cervical spine is indicated if there is pain localized to the neck or of a radicular nature that is subacute or chronic with failure to improve after six or more weeks of non-operative treatment and the enrollee is being considered for invasive treatment and there is significant interference with daily function. Conditions, such as obtunded or temporary non-assessable status, polytrauma, and neurologic deficit are predisposing factors for injuries discovered on an MRI but missed on computed tomographic scan alone. These findings can affect the management of acute cervical spine fractures.  MRI can diagnose intrinsic spinal cord injuries. In this case, no clear, significant trauma concerning for fracture or hematoma is evident. The medical literature indicates an MRI of the cervical spine is indicated if there is pain localized to the neck or radicular in nature; the pain is subacute or chronic, with failure to improve after six or more weeks of conservative treatment; the patient is being considered for invasive treatment; and there is significant interference with daily function. The record indicates the enrollee has complaints of pain to the neck and to the base of the skull.  However, there is insufficient evidence in the record of the enrollee completing a conservative treatment course of six weeks or more.  Notes do not indicate the enrollee is being considered for invasive treatment or there is significant interference with daily function.  There are no specific deficits noted on the physical examination.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurological 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz. Tofacitinib is a safe and effective treatment for severe alopecia areata and may be considered in patients with longstanding disease with worsening symptoms despite other available therapy. a study of 90 patients with at least 40% scalp hair loss. The authors found that 77% of patients treated with tofacitinib achieved a clinical response, with 58% of patients achieving greater than a 50% change in Severity in Alopecia Tool (SALT) score. They also found that tofacitinib was well tolerated, and without serious adverse effects. while treatment of alopecia totalis and alopecia universalis is often challenging and unsatisfactory, oral tofacitinib was more effective than diphenylcyclopropenone immunotherapy and more tolerable than conventional oral treatment after six months of treatment. Janus kinase (JAK) inhibitors have substantial efficacy in the treatment of alopecia areata. In this case, the patient has tried and failed standard topical and intralesional corticosteroids and reports previous success with Xeljanz. In this clinical setting, given the patients documented improvement with Xeljanz, the requested medication is more effective than any other standard therapy and is a well-known and commonly used therapeutic for alopecia areata. Therefore, Xeljanz is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz 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 medication 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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 52-year-old male enrollee has requested for intensity modulated radiation therapy for treatment of his moderately differentiated adenocarcinoma arising at the gastroesophageal junction. Findings:  The physician reviewer found that there is a lack of support in the literature demonstrating superior results of intensity modulated radiation therapy compared to 3D technique in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-four year-old female with premenopausal osteoporosis is requesting authorization of treatment with Zometa.Reviewers Findings:  The reviewing physician found that the patient is obviously at high risk with apparent premature osteoporosis.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested bunionectomy and hammertoe correction surgery for treatment of his bunion and foot pain.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedures. Bunions and hammertoes are physical malformations that do not allow patients to fit into shoes comfortably and cause pain. The medical records submitted for review note that the patient is in pain because of his bunion and hammertoes and that the patient is unable to wear shoes or ambulate comfortably. The patients physical malformations are well noted and documented in the progress notes, both via physical examination and x-ray. Furthermore, the requested bunionectomy and hammertoe correction for this patient meets generally accepted standards of medical practice criteria. All told, the medical necessity of the requested procedures has been established.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old female enrollee requested  panniculectomy with extended abdominoplasty for  medical treatment of her excess skin.  Findings:  The physician reviewer found that a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. As noted by Manahan and Shermak, common functional problems associated with an overhanging pannus or skin redundancy are described to cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. All told, the requested panniculectomy has been documented to be reconstructive in nature and medically necessary, and the extended abdominoplasty is not reconstructive in nature and not medically necessary for treatment of this patients excessive skin and soft tissue secondary to weight loss.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee requested adolescent mental health residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that residential treatment center (RTC) services were medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, this patient has an extremely severe case of obsessive-compulsive disorder that has made him unable to function outside a regulated and highly structured environment.  The record further documents that he has deteriorated previously when he was discharged from this structured environment to a less structured one.  Based on documentation submitted for review,  RTC level of care is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested gastric bypass surgery for treatment of her obstructive sleep apnea and obesity.  Findings:  The physician reviewer found that based on review of the available records, although the patient does not have documentation of six months of consecutive supervised weight loss, the patient does meet standard nationally accepted guidelines for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. This patient has a BMI that is greater than 40, or at least 35 with one or more serious co-morbid conditions. The records indicate the patient has a BMI of 53 as well as several weight related co-morbid conditions. In addition, she completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary or behavioral, or medical barriers to surgery. She has failed weight loss efforts in the past and lost pre-operative weight as requested by her provider to clear her for bariatric surgery. Consistent with these findings, the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested for use of a pneumatic compression device for treatment of her medical condition status-post bilateral meniscus tear.  Findings:  Three physician reviewers found that the literature indicates that cooling/compression devices have been used in postoperative knee surgery care. But, the studies do not prove that the use of compression devices improve or accelerate positive outcomes as compared to other treatments.