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

A 53-year-old male enrollee has requested residential treatment services for treatment of his substance abuse.  Findings:  The physician reviewer found the records provided  indicate the patient did not have acute psychiatric or medical symptoms that would have interfered with his maintaining abstinence and recovery outside of a 24-hour structured setting. In addition, there is a lack of documentation that treatment had been attempted at a lower level of care. Overall, the patient did not show any evidence of major functional impairment in his ability to perform activities of daily living, participate in interpersonal relationships or work. The patient was not showing active signs of withdrawal at the time of residential admission. His relationship with his wife has been impaired by his substance abuse but not to the extent that his home environment was unstable requiring treatment in a 24-hour residential setting. He was attending groups and therapy sessions and was motivated to change. Based on the documentation, the patient could have been safely and adequately treated in a lower level of care such as intensive outpatient or office based setting. Thus, the residential treatment services were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested coverage for past blood testing for food allergies with IgG allergy testing for evaluation of his allergies.  Findings:  Three physician reviewers found that the patient has a medical history of hypertension and ADAM syndrome. The patient has symptoms of abdominal bloating and diarrhea for several months. No laboratory or imaging data is available for review. The provider recommended evaluation for gluten intolerance. The provider ordered IgG Food Antibody Assessment with IgE Foods an IgE Inhalants. Gluten intolerance or gluten enteropathy is a diagnosis based on history, physical examination, and specific laboratory testing including serum celiac panel (IgG anti tissue transglutaminase antibodies, IgG endomysial antibodies, and/or IgG deamidated gliadin peptide). The diagnosis is confirmed with small bowel biopsy. If the above tests are positive, a trial gluten-free diet can be initiated with observation for clinical improvement. However, the diagnosis is not made with the use of IgG and IgE Food Antibody testing. Food allergy testing is based on a very specific history, food challenge, skin prick test and measurement of specific IgE antibodies to food extracts, individual allergens, or allergenic peptides. Indiscriminate testing is not helpful and yields a rate of high false positive results. In the peer-reviewed medical literature, food specific IgG and IgG4 testing is not supported as a first-line evaluation modality. Specifically, it does not detect true food hypersensitivity and may actually be a marker for development of tolerance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar spinal fusion for treatment of the enrollees moderate to severe two level stenosis at L2-4. Findings:  The physician reviewer found that The medical records document that the patient has spinal stenosis above the level recommended for fusion at the L2-4 levels. However, there is no spinal instability, fracture, or tumor present to support an indication for spinal fusion. The role of fusion, in the absence of a degenerative deformity, is uncertain. Thus, the requested lumbar spinal fusion is not medically necessary for treatment of his spinal stenosis. 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: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee requested reimbursement for adolescent substance use disorder residential treatment for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found in the submitted documentation that the patient was attending off-site Narcotics Anonymous meetings during the disputed period. The medical records for the date in question noted that the patient was attending all groups. The medical notes indicated that the patient was doing well. The clinical records provided did not reflect emotional or medical instability that required 24-hour supervision under a physicians care during the dates in question. The patient had progressed to the point that he was a candidate for transitioning from residential treatment to a less restrictive level of care. Based upon the American Academy of Child and Adolescent Psychiatry practice parameters, residential treatment was not medically necessary on the date in question.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a six-year-old boy who has been diagnosed with idiopathic short stature.  When seen in August 2005 at the age of 5 years 5 months he was below the third percentile for height and at about the tenth percentile for weight. His growth rate over the past year was documented as 2.8cm per year.  A bone age study completed in the same timeframe was read as 2 years and 8 months. Thyroid tests were normal as was an MRI examination of the pituitary gland.  It appears that growth hormone was prescribed in October 2005 and the patients parents have requested authorization for the therapy. The Health Plan determined the therapy is not medically necessary and denied their request.The records provided for review do not suggest a diagnosis of growth hormone deficiency.  The blood levels of growth hormone dependent IGF-1 and IGFBP-3 were normal and the brain MRI study showed a normal pituitary gland. Similarly, there is no indication from the record the patient was small for gestational age and has failed to achieve appropriate catch-up growth. The patients growth rate has been modest, but that in it self is not a basis for growth hormone therapy at this age. It appears likely from the clinical data that the patient has a constitutional delay in growth. The delayed bone age will provide additional opportunity for growth.   Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 17-year-old male enrollee have requested growth hormone (GH) therapy for treatment of short stature.  Findings:  The physician reviewer found that this request is for GH therapy for a 17-year-old male with short stature who has a predicted adult height of 54 against a mid-parental height of 58.5. A work-up prior to this excluded GH deficiency and other known causes of short stature including SHOX. A bone age was read as 16 years. The patients growth response after Lupron and GH therapy was initiated was 0.6 cm over five months for a low yearly rate of 1.44 cm. The pediatric endocrinologists note stated that, unless growth has increased during the next three to six months, any benefits of continued therapy may be minimal. Indeed, intervention at this late stage would be expected to be marginal.  However, the predicted height of 54 is borderline low for adult men in the United States, under the FDA guidelines for GH therapy for idiopathic short stature. Therefore, on clinical grounds, continuation of GH therapy would be appropriate to determine conclusively whether there is a therapeutic benefit in further treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral sacroiliac joint fusion or radiofrequency for treatment of the enrollees bilateral sacroiliac joint pain.  Three physician reviewers found that the requested services are not likely to be of greater benefit than other treatment options.  The documentation submitted for review indicated previous sacroiliac injections were 100% successful in controlling the patients pain and the pain relief lasted for two months.  However, there was no indication the patient continued to have facet joint pain, signs and symptoms on the physical examination.  Details regarding previous conservative therapy, such as medication, physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions, were not provided for review.  The current medical evidence does not support the requested services in this clinical setting.   Final Result: Three reviewers determined that requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

A 21-year-old male enrollee has requested transcranial magnetic stimulation therapy for treatment of his bipolar 1 disease with severe depression. Findings:  Three physician reviewers found that at this time, there is insufficient evidence supporting the efficacy of transcranial magnetic stimulation to warrant its use in this setting. The data submitted for review does not demonstrate that the Food and Drug Administration (FDA) criteria for these services were met. Transcranial magnetic stimulation is FDA-approved for unipolar, non-psychotic patients with major depressive disorder which has not responded satisfactorily to one antidepressant medication at therapeutic dose and duration in the current episode. This patient has been diagnosed with bipolar I disorder. There is no documentation of a diagnosis of major depressive disorder. Most studies on transcranial magnetic stimulation in psychiatric disorders have focused primarily on unipolar depression. At this time, there is limited data concerning the potential efficacy of transcranial magnetic stimulation in the treatment of bipolar depression. Given the lack of scientific evidence demonstrating that transcranial magnetic stimulation results in a superior clinical outcome as compared to standard therapies in this patient population, the services provided were not likely to be more beneficial for this patient than standard treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV).  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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL, ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: An enrollee has requested authorization and coverage for hyaluronate injection/Synvisc One injection.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Current guidelines do not support the use of these injections in patients with patellofemoral arthritis or chondromalacia patella, or for repeated use if the patient did not achieve significant improvement in symptoms for six months or more. In this case, the patient presents with persistent right knee pain, worse with weight-bearing activities. Clinical examination findings have been consistent with imaging evidence of patellofemoral and medial compartment chondromalacia, with no significant joint space narrowing documented. She is status post a series of viscosupplementation injections , with a lack of evidence of a significant improvement in symptoms for six months to support the medical necessity of repeat injections. She was again reporting increased pain and functional limitations . Evidence-based medical criteria have not been met to support the medical necessity of this request. Therefore, the requested hyaluronate injection/Synvisc One injection is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested skilled nursing services for the treatment of her medical condition.  Findings:   The physician reviewer found that there is limited high-grade evidence guiding the optimal rehabilitation strategies following distal radial fractures and ankle/foot fractures.  The patient has been placed on non-weight-bearing restrictions for one upper limb and the contralateral lower limb due to her recent left distal radial and right foot fractures.  She has made some progress with respect to self-care abilities, but has plateaued at requiring some assistance for her lower body self-care and transfers.  She has remained non-ambulatory.  There are no indications that she has been self-propelling a wheelchair.  There is no indication that caregiver training has taken place.  There is a lack of support for the services at issue in this clinical setting.  All told, skilled nursing services are not medically indicated for the treatment of 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 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: Upheld

A 63-year-old female enrollee has requested for a spinal cord stimulator for treatment of his back pain.    Findings:  The physician reviewer found that a spinal cord stimulator is used for severe, chronic, disabling neuropathic pain with a clear etiology (e.g. post-laminectomy syndrome or perineural fibrosis).  This procedure is not generally performed for primarily back pain radiating to the leg with no clear neuropathic cause.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested intracapsular enucleation for medical treatment of her vagal nerve schwannoma.  Findings:  The physician reviewer found that although this patients tumor is considered benign, the records demonstrate that it has shown growth over the period of observation. The patient is young and delaying surgery in this clinical setting slowly increases the risk of damage, both from the tumor itself and the slowly increasing complexity of the necessary surgery. These are rare tumors and it is medically necessary for this patient to have the surgery performed by an experienced surgeon to decrease the chances that she will require additional procedures to address laryngeal or other potential consequences. All told, the requested surgery consisting of intracapsular enucleation is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Based on LOCUS criteria, this patient met the criteria for IOP services. The patient was at low risk of harm (score 2), as she had self-reported suicidal ideation during her days prior to discharge without an active plan. The patient demonstrated mild functional impairment (score 2). The records document that the patient has a strained relationship with her family and has plans to attend college. The patient has significant comorbidities (score 3), as she has a history of an eating disorder with food restrictions that have resulted in unstable vital signs. She had a low heart rate and orthostatic vital signs. Moreover, the patient has not started menses due to her anorexia. The patients recovery environment was mildly stressful (score 2) due to her strained relationship with her family. The patients recovery environment was supportive (score 2), with community resources in place with an outpatient therapist. The patient has shown moderate response to treatment (score 3) and was described as adherent with her program but struggled with her anorexia during outpatient treatment. This gives the patient a composite score of 14, which is consistent with low intensity community-based services, similar to the services provided to this patient at the IOP facility during the period under review. All told, the IOP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Urgent Care
Decision: Upheld

A 31-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he 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. This patients symptoms had been present for two months prior to his visit to the emergency department. He had already previously been evaluated by his primary care doctor and received prescription medication. There was no sudden change in his condition on the date of service at issue which would have caused a prudent layperson to seek emergency department care. The patient was not experiencing any acute neurologic deficits (such as vision changes, nausea or vomiting) and he denied any chest pain or shortness of breath. While the patients symptoms may have warranted a medical evaluation, a prudent layperson in this patients circumstances would not reasonably believe that this evaluation needed to be provided on an immediate basis. The patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for two epidural injections. The enrollee has lumbar disc degeneration, lumbar radicular pain, low back pain, pelvic pain, left hip pain, and sacroiliitis. At an office visit, she reported lumbar spine pain with radiation to her groin and legs and pain around her left hip. She reported weakness, which resulted in an inability to walk. The enrollee reports the injections relieved her back pain for about six months. She underwent two epidural injections. This enrollees physical exam reports motor weakness in the left leg knee extenders and flexors, as well as weakness in left ankle dorsiflexion. This enrollee has all of the evidence-based criteria for an epidural steroid injection. A randomized controlled trial studied lumbar transforaminal epidural steroid injection for radicular pain secondary to disc herniation. The authors found 54 percent of individuals treated with transforaminal injection of steroid achieved pain relief. Outcomes were similar for those with acute or chronic radicular pain. This study provides evidence that, for persons with lumbar disc herniation, lumbar transforaminal epidural steroid injection provides a greater than 50 percent relief of pain for 54 percent of recipients at one month after treatment, it is significantly more often effective than sham and other treatments, and lumbar transforaminal epidural steroid injection substantially reduces the need for surgery.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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.