Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 16-year-old male has requested Enbrel 50mg subcutaneous injection, twice weekly for three months, followed by Enbrel 50mg once weekly for treatment of his moderate to severe chronic plaque psoriasis.  Findings:  Three physician reviewers found that the patient has chronic plaque psoriasis affecting approximately 20% of scalp and skin and has failed standard topical and systemic therapies. Considering contraindications to systemic cytostatic and immunosuppressors, his provider has prescribed treatment with etanercept (Enbrel).  Psoriasis is a chronic inflammatory skin disease affecting approximately 2% of the US population and 4.8% of people worldwide. Approximately 30-45% of those affected first experience symptoms during childhood or adolescence (Marji, et al). Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of biologic therapies for the treatment of moderate-to-severe psoriasis has been a major clinical and research focus (Patel, et al). Enbrel is effective and well tolerated in children and adolescents with moderate-to-severe plaque psoriasis (Beikert, et al; Papoutsaki, et al). This patient has widespread plaque psoriasis that requires systemic treatment. However, the medications traditionally used in adults such as methotrexate and cyclosporine are contraindicated for use in children and adolescents. These facts, taken together with the good safety and efficacy profiles of Enbrel in children and adolescents, indicate that use of this medication is likely to provide this patient with an improved health outcome beyond that expected with standard alternative therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a sumatriptan injector pen dosed at 6 mg two (2) times a day (60 pens per 30-day supply). The U.S. Food and Drug Administration (FDA) approves the use of sumatriptan injections for the treatment of cluster headache episodes. In this case, the patient has been diagnosed with cluster headaches and has been approved for sumatriptan vials. Given that an autoinjector reduces the risk of overdosing and allows the patient to carry the medication with her outside of the home, the requested medication is medically indicated. Additionally, two shots per day is also appropriate. In terms of safety, the maximum is dose is 12 mg in 24 hours. Therefore, a sumatriptan injector pen dosed at 6 mg two (2) times a day (60 pens per 30-day supply) 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested  breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages this technique brings to radiologists in the interpretation of mammograms. The advantages the technique offers relates to the tomographic nature of tomosynthesis which helps radiologists differentiate dense glandular tissue from architectural distortion which in turn decreases callbacks and increases detection of small cancers. For these reasons provided, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only.  Final Result: Two 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: All three reviewers are board certified in diagnostic radiology 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: Overturned

A 55-year-old female enrollee has requested Botox injections for the treatment of headaches.  Findings:  Two physician reviewers found that Botox has considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). Response is often greater over several treatment cycles.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient hospitalization for treatment of his medical condition. Findings: The physician reviewer found that although the patient was not suffering from an acute psychiatric syndrome, his presentation was consistent with the conceptualization of grave disability as he had significant impairment across multiple domains. Since he  remained debilitated by psychiatric symptomatologies, an inpatient residential stay was indicated.  Per the medical records, treatment could not have been safely or effectively delivered in a setting less restrictive than the inpatient venue at the time. The patient was engaged in active treatment delivered in accordance with a treatment plan that was reasonably expected to improve his condition and prevent a more serious episode of illness. In sum, inpatient hospitalization was medically indicated for the 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested spinal decompression therapy for the treatment of her low back pain. Findings:  Three physician reviewers found that the submitted clinical documentation does not indicate what other chiropractic therapies had been tried and failed prior to the patients treatment using spinal decompression therapy. In addition, the current scientific literature fails to prove that spinal decompression therapy is a superior form of treatment for this patients condition. There have been no long-term studies or research performed utilizing this type of therapy. As noted in a paper by Daniel, There is very limited evidence in the scientific literature to support the effectiveness of non-surgical spinal decompression therapy. This intervention has never been compared to exercise, spinal manipulation, standard medical care or other less expensive conservative treatment options which have an ample body of research demonstrating efficacy. All told, there is inadequate scientific data demonstrating the efficacy of spinal decompression therapy for the treatment of back pain.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested a magnetic resonance angiogram (MRA) of the head and magnetic resonance imaging (MRI) scans of the brain and cervical and thoracic spine for an evaluation of her medical condition. Findings:  The physician reviewer found that this patient had a variety of symptoms including mild memory complaints, ear pain, fatigue and depression, among others. A neurologic exam by a primary care physician was normal, but a brain MRI was performed. She subsequently had neurologic exam by a neurologist, which was normal. No history was elicited to suggest diagnosis of clinically isolated syndrome, or multiple sclerosis, but extensive neurological imaging (MRA of the head and the MRIs of the brain and cervical and thoracic spine) was ordered as a follow-up of her prior MRI scan. The literature shows that a variety of non-specific findings may be discovered on unnecessary testing, such as the T2 white matter findings commonly seen in brain MRI of individuals with migraines, as appears likely in this case. No evidence is present in the medical records that the diagnostic procedures performed were medically indicated or necessary for the evaluation of the patients mild memory loss complaints, fatigue or for a follow-up of her previous brain MRI.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services provided from 1/25/17 through 6/07/17. The Health Plan has denied this request indicating indicates that the enrollees condition does not meet the emergency and medical necessity criteria for the services at issue. Findings: The patient presented for an initial psychotherapy consultation on 1/18/17. Her diagnoses included panic, major depressive disorder, and obsessive-compulsive disorder. Her symptoms included poor self-regulation, impulsivity, irritability, and reported difficult coping with life stressors. Given her assessment on 1/18/17, there is ample evidence to argue for the medical necessity of ongoing regular psychopharmacology and psychotherapy treatment. Maintenance psychotherapy was appropriate to treat this patients condition, is consistent with good medical practice and is medically necessary.  After months of treatment, this patients condition cannot by definition, be an emergency.  Though it might be important and medically necessary, it should not be covered under the emergency provisions for this patient, but rather it should be diagnosed as necessary non-emergent treatment. The treatment provided does not meet the definition of emergency services as defined by the California Health and Safety code. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the services at issue were not emergency medical services for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee requested abdominoplasty for medical treatment of her medical condition status post laparoscopic gastric band placement.  Findings:  The physician reviewer found that Coriddi and colleagues evaluated functional status following abdominoplasty and noted that, rectus plication did not significantly improve functional outcomes. Thus, the medical literature does not adequately establish that there is direct functional benefit from muscle plication. Overall, this patients documented diastasis is mild as demonstrated on CT scan and the scientific evidence does not provide sufficient justification for abdominal muscle plication in this clinical setting. Therefore, the requested abdominoplasty is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the patients CIWA score of mild to moderate withdrawal symptoms meets this criterion. The patients meets dimension 2 given the presence of significant hypertension worsening with withdrawal. For dimension 3, the patient has a comorbid diagnosis of depressive disorder. The records support evidence to meet dimension 4, as the patient is noted to be engaging in self-sabotaging behaviors. The provider noted that the patients insight is partially improved, but he still needs to learn alternative coping skills to deal with emotional distress. For dimension 5, the patients avoidance and isolation with partial insight present risks for relapse. At this stage of recovery, the patient is unaware of his relapse triggers. The patient also meets the criterion for dimension 6, as he hosts social events serving alcohol, as he owns a vineyard. The patient requires a safe and stable living environment in order to develop his recovery skills. The patient meets the ASAM Level III treatment level of care, which is similar to the services provided at the current RTC facility. Given the severity of the patients illness, 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 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 for a standard manual wheelchair. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Physical activity and exercise are generally appropriate and recommended for conditions such as obesity and diabetes.  In this case, the patient uses a power wheelchair for mobility.  The records do not establish that the patient is capable of safely propelling a manual wheelchair or why a manual wheelchair is specifically being requested with respect to the patients functional needs, given that he has a power wheelchair that meets his mobility-related activities of daily living needs.  This type of information is necessary for prescribing any mobility device, including a manual wheelchair.  A detailed physical examination and functional evaluation, moreover, is important for properly prescribing a manual wheelchair that is not going to cause injury to a user.  This information is also not documented in the available records.  Final Result: The reviewers determined that the requested equipment 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found the medical services provided were not necessary for treatment of an emergency medical condition. The patient presented with a headache that had been present for two weeks. The patient reported occasional numbness of the area and ear congestion. The patient was afebrile. The neurologic examination was normal. The patients pain worsened with neck range of motion. The radiologic studies were ordered on an outpatient basis. A thyroid ultrasound was not indicated for an acute complaint. Although imaging may have been indicated, there was no emergent indication for the neck x-rays, brain CT scan, or thyroid ultrasound. In addition, the patients symptoms were not sudden or acute. In sum, the patient did not receive emergency medical services on the dates of service at issue. 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 emergency 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

The parent of a 20-year-old male enrollee has requested 10 hours of applied behavioral analysis (ABA) for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient carries dual diagnoses of autism and moderate intellectual disability. He has previously been treated with at least three years of ABA therapy. According to his school records, the patients behaviors and social skills have failed to significantly improve despite several years of ABA therapy. A study by Remington and colleagues describes the effectiveness of ABA therapy for autistic children. The authors found that after two years of therapy, children had made significant gains in improved behavior and IQ. In assessing the efficacy of ABA therapy for individual patients, there should be evidence of documented gains in behavior, social skills, speech and/or communications skills within a two-year period of the patients participation in ABA therapy in order to find the therapy effective. In this patients case, his vocabulary is limited to 200 words despite three years of prior ABA therapy. Based upon the clinical information provided, ABA therapy has not been effective for the patient. There is a lack of evidence that continuation of ABA therapy is likely to result in meaningful improvement in the patients condition. As such, the medical necessity of the requested services has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A thirty year-old female diagnosed with an ependymoma in the lumbar spine is requesting a referral for treatment.  Reviewers Findings:  The three reviewing physicians found that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested for Tysabri infusions for treatment of her multiple sclerosis. Findings:  The physician reviewer found that review of the scientific literature reveals that Tysabri has shown better efficacy than interferons in indirect comparisons. Per FDA prescribing information, Tysabri is indicated as monotherapy for the treatment of patients with relapsing forms of MS to delay the accumulation of physical disability and reduce the frequency of clinical exacerbations.. Per TOUCH program guidelines, it is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, alternate multiple sclerosis therapies. No recommendation is made that it be given only if a patient has failed two prior disease modifying MS therapies.
Appeal type: Urgent Care
Decision: Overturned

A 66-year-old female enrollee has requested emergency room services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, would believe he or she was experiencing an emergency medical condition on the date of service at issue requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that the patient was experiencing an emergency medical condition upon presentation to the Emergency Department. The physician gave the patient prescriptions for multiple potent medications to treat her illness, an indication of the seriousness of her clinical situation. Acute wheezing, particularly in a non-asthmatic individual, with or without perceived shortness of breath, chest pain or fever, is considered a medical emergency by emergency physicians and likewise should be perceived as a medical emergency by a reasonable and prudent layperson.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric services provided. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the date of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.Based on the documentation submitted for review, the patient did not receive emergency medical services on the date of service at issue. In this case, the documentation submitted for review does not show an evaluation was performed on the date of admission to residential treatment. The standard of care for emergency inpatient programs is for new patients to be evaluated, and treated by a provider within 24 hours. From tthe patient documentation provided, this was not done. Moreover, there was no documentation demonstrating that the patient was acutely suicidal at the time of admission, was psychotic, manic, medically ill or had any other acute condition that required emergency treatment. Therefore based on the information provided, the patient did not receive psychiatric emergency medical services.  Final Result: The reviewers determined that the patient did not receive psychiatric emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.