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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica for treatment of the enrollee, who has a history of diabetic polyneuropathy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Gabapentin is eliminated from the systemic circulation by renal excretion as unchanged drug. Gabapentin clearance is directly proportional to creatinine clearance, which is reduced in this case. The Health Plan requires that the patient try a higher dose of gabapentin prior to authorizing Lyrica, but his provider declines to do so because of the decreased creatinine clearance. The Health Plan requires him to try a tricyclic antidepressant for at least eight weeks. However, both tricyclic antidepressants have the major side effect of tachycardia. This patient has his heart rate controlled with beta blockers to treat his congestive heart failure, so a trial of a medication which is known to cause tachycardia is a poor choice.  The medical evidence supports Lyrica in this clinical setting. All told, the requested medication Lyrica 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested authorization and coverage for Saphris 30mg per day for treatment of the enrollees schizophrenia, paranoid type. Findings:  The physician reviewer found that this particular case represents an off-label treatment recommendation, as the dosage of medication exceeds the recommended limits established by the United States Food and Drug Administration (FDA). Although off-label prescribing is common, it has the potential to undercut expectations that drug safety and efficacy have been fully evaluated (Stafford).   As presented, there is no evidence of recalcitrant symptoms that endanger the patient or others.  There is no description that this particular regimen is averting the need for treatment in a more restrictive level of care.  Further, the specific outcomes of previous systematic medication trials, and non-medication therapies, are unknown.  Finally, there are no well-developed studies in the peer-reviewed literature that demonstrates either superiority or safety of asenapine (Saphris) 30mg daily compared with the FDA maximum dose of 20mg per day.  In the absence of evidence-based literature supporting this particular regimen and additional rationale in the medical record, which would ideally identify specific standard first-line medication failures, the requested medication is not medically necessary. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-eight year-old female with chronic kidney disease and hypertension is requesting continued care related to renal transplant at an out-of-network facility.Reviewers Findings:  The reviewing physician found that the transfer to an in-network facility is considered safe because if the patient undergoes renal transplant, the transplant would not be delayed by the transfer.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male enrollee has requested inpatient rehabilitation/detoxification for treatment of his substance use disorder.  Findings:  The physician reviewer found that the records indicate the patient had been tried on outpatient treatment with poor success due to noncompliance with attendants and following the treatment regimen. The patient was started in what appears to be intensive outpatient treatment (IOP), which he did not regularly attend and did not follow the prescribed recommended treatment options in that program. The American Society for Addiction Medicine (ASAM) criteria for acute inpatient hospitalization requires the patient to be a severe withdrawal risk. The patient must require constant supervision for withdrawal symptoms and may present with severe psychiatric symptoms which require 24-hour observation. The criteria suggest the patient may show difficulty with acceptance and treatment and may be in an environment that is dangerous or logistical concerns impede the patients treatment. Overall, the records do not indicate that he was showing any worsening of his psychiatric symptoms necessitating 24-hour supervision and care. Ultimately, the patient does not meet the criteria for an acute inpatient detoxification and CD treatment based on the ASAM criteria for that level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested for acupuncture for treatment of her chronic pain syndrome. Findings:  The physician reviewer found that the patient is currently on disability, can no longer drive a car, lives at home with her mother and needs some assistance with activities of daily living. Based on review of the submitted records, it does not appear that the patient has had any significant improvement in her symptoms/complaints with any of the prescribed therapies/modalities/medications including acupuncture.
Appeal type: Medical Necessity
Decision: Upheld

A twenty-four year-old female with a history of alcohol and cocaine abuse is requesting reimbursement for acute inpatient psychiatric services.  Reviewers Findings:The reviewing physician found that the submitted clinical information does not substantiate the need for acute inpatient psychiatric treatment.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a custom-fitted mandibular advancement oral device. Researchers note that the mandibular advancement oral appliance is frequently an option for the treatment of mild obstructive sleep apnea (OSA), modifying the upper airway and improving the airway patency. In this case, the patient has mild OSA. While she reports clenching and grinding her teeth, this is not a contraindication to oral appliance therapy. Given that an oral appliance device is standard of care in treating mild OSA and recommended by the provider, the requested device is medically indicated. Therefore, a custom-fitted mandibular advancement oral device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 otolaryngology  head and neck 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

A 57-year-old female enrollee has requested for laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity without participation in the Options program.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 44.6 and significant comorbidities that will likely be ameliorated or eliminated by bariatric surgery. She requires immunosuppression and medications that may inhibit the healing process due to her severe arthritis, making the Lap Band procedure the most appropriate surgical alternative for weight loss. With regard to the Positive Choice program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, it does not appear that she has undergone surgical evaluation or obtained psychological clearance for the procedure.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for a Flexitouch pneumatic compression device and half leg garment. The submitted documentation does not support that the requested pneumatic compression device and associated half leg garment are medically necessary at this time. Intermittent pneumatic compression using a pump with leg garment can be a useful complement for maintenance edema management, with the foundation of care being compression wraps/garments. Intermittent pneumatic compression, however, is not a substitute or alternative for appropriate conservative care, particularly given that intermittent pneumatic compression may cause complications and it may not be well tolerated. In this case, there is insufficient documentation that the patient has undergone formal complete manual lymphatic drainage therapy demonstrating significant edema reducibility in the affected lower limb. A rigorous trial of compression wraps/garments after successful complete manual lymphatic drainage would be appropriate conservative care in this patient's setting. While the submitted records reflect that the patient has undergone lymphedema therapy, there is no clear evidence of significant volumetric reduction (i.e., with measurements). Moreover, there was evidence of noncompliance with compression garment use at home. Under these circumstances, a Flexitouch pneumatic compression device and a half leg garment are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested devices 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Additionally, the literature indicates that if there is significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. In this case, the patient has been diagnosed with osteoarthritis of the knee. The patient has reported severe right knee pain with functional limitations in walking and prolonged sitting. Clinical examination was consistent with x-ray findings of bilateral knee osteoarthritis, including medial joint space narrowing and tricompartmental osteophyte formation. The records note that the patient has failed to adequately respond to other conservative treatment including activity modification, medications, and home exercise. The patient reported that the patient does not want to undergo further corticosteroid injections due to health concerns. Prior Synvisc injections to the right knee have provided six to 12 months of pain relief and functional improvement. Therefore, the requested Synvisc injections are medically necessary for treatment of the patients medical condition. Final Result: The physician 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 physician 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center services. Applying CALOCUS, this patient meets the criteria for RTC services. The patient has been at significant risk of harm (score 3) due to a recent history of risky behaviors. The records document behavioral issues including aggression, running away, substance use, and inappropriate relationships with older men. The patient has exhibited serious functional impairment (score 4) considering the ongoing conflict with her parents and repeated altercations with peers in the structured treatment settings. She also has a recent pattern of excessive substance use resulting in harmful behaviors. The patient has significant comorbidities (score 3) due to substance use, mood swings, and PTSD symptoms. The patients recovery environment is moderately stressful (score 3). The patient has issues with substance abuse, legal and school difficulties, and conflict with her parents. The patients environment is described as supportive (score 2) as her parents have attempted to arrange for treatment and support the patients recovery with family therapy. The patient has demonstrated poor response to treatment (score 4), as the providers reference multiple prior RTC admissions and lack of progress in the current RTC. The patient has been incompletely engaged in treatment (score 3). She has experienced difficulty opening up in treatment and with being honest. This gives the patient a composite score of 22, which is consistent with medically monitored community based services. However, the patients score of 4 on functional impairment and scores of 3 and 2 on recovery environment support Level 5: medically monitored residence based services, such as RTC level of care. Furthermore, the patient meets criteria for Level 5C: long-term medically monitored residence based services, due to minimal past response to treatment and inability to maintain any gains achieved outside an intensive and highly structured setting (Klaehn, et al.). Given these findings, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injection in the right knee. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient does not have history of treatment with prior viscosupplementation. However, the options have been tried including non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, cortisone injection, platelet rich plasma, and knee aspiration without significant relief. For these reasons, the requested Monovisc injection in the right knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

A 51-year-old female enrollee has requested Botox therapy for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the submitted documentation notes more than a 50% improvement in headache frequency as well a moderate decrease in headache intensity with Botox injections. This patient has a history consistent with chronic migraine which has significantly affected the quality of her life. She has tried and failed all of the approved medications for migraine prevention. She has shown a good response to Botox. Botox is now FDA approved for the treatment of chronic migraine and has been shown to be safe and effective in the published literature. Several large, double-blinded, placebo controlled studies have documented the effectiveness of Botox in chronic migraine. In light of published outcomes data, the patients failure to respond to traditional preventive agents and her proven response to Botox, I find that the requested therapy is likely to be superior to any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a six-year-old male with a history of chronic eczema. The patients mother indicates the patient has attempted multiple treatment medications without sustained benefit. The patients mother has requested coverage for homeopathic treatment. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is no evidence-based research showing homeopathy to be safe and/or effective for treatment of eczema. Ultraviolet therapy, the alternative treatment recommended by the Health Plan, is medically appropriate and reasonable for treatment of eczema. The patient is likely to experience a better clinical outcome with ultraviolet therapy than with homeopathy, an unproven therapy. As such, I have determined that the requested therapy is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested inpatient hospital treatment for treatment of the enrollees major depression and polysubstance abuse. Findings:  The physician reviewer found that this patient continued to meet criteria for inpatient treatment given the severe disturbance of affect, feelings of hopeless and helplessness, and fleeting suicidal ideation.  He was at risk for escalation of symptoms at a lower level of care and could not have been managed safely in a less restrictive environment. When determining level of care, comorbidity must be considered, such as depression, substance abuse and severe functional impairment, which were all noted in this case. The level of care provided was consistent with community standards of practice and American Academy of Child and Adolescent Psychiatry practice parameters.  All told, inpatient hospital treatment provided during the time period at issue was medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 28-year-old male enrollee has requested reimbursement for ophthalmology services provided on the basis the services were emergent in nature.  Findings:  The physician reviewer found that a central retinal vein occlusion whether ischemic or non-ischemic is not a medical emergency that requires emergent treatment (Hahn, et al. and Ho, et al.)  While it is a serious problem, in this case, appropriate treatment was being provided in-network. Although the in-network specialist did not order a fluorescein angiogram to distinguish ischemic from non-ischemic, this is not necessary for making the diagnosis and proper management and is also not an emergency. Therefore, the condition for which the patient sought services on did not meet the definition of an emergency medical condition under California law. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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.