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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for behavioral health psychological testing. The American Psychiatric Association (APA) recommends that psychological testing be used in conjunction with other sources of clinical information, including a clinical interview, interviews with collateral sources, self-reported objective measures, observation of the patient, and review of past records, to create a diagnostic formulation and treatment plan. Psychological and neuropsychological testing may be used to narrow the differential diagnosis when there is lack of diagnostic clarity or lack of progression according to the treatment plan due to possible functional and cognitive limitations, which are not elucidated in the course of a clinical interview and treatment. In this case, the submitted clinical interview, past records, and observation of the patient do not establish a lack of diagnostic clarity or inability to create treatment recommendations. While the patient would benefit from a thorough psychiatric evaluation, including collateral information and objective measures to help direct treatment modality and establish diagnosis, in this clinical setting, the submitted documentation does not establish the lack of clarity in diagnoses necessitating psychological testing. Therefore, behavioral health psychological testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation 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 67-year-old male enrollee has requested left ankle surgery for treatment of his ankle deformity.  Findings:  The physician reviewer found that tt is appropriate to delay the requested arthrodesis of the tibiotalar joint until after the patient ceases smoking. Arthrodesis of the ankle is a complex procedure in which successful arthrodesis is not at all guaranteed or easily achieved. It is an elective procedure for a chronic problem. The broken medial malleolar screw is not significant as a pain generator. The tibiotalar joint has been demonstrated to have advanced degenerative osteoarthritic changes and is the likely source of pain. The condition at the left ankle provides an appropriate indication for arthrodesis if the patient stops smoking.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male has requested occupational therapy services for treatment of the enrollees pervasive developmental disorder.  Findings:  The physician reviewer found that autism spectrum disorder (ASD), of which pervasive developmental delay (PDD) is one manifestation, is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with ASD. Typically, young patients on the autistic spectrum require interventions in multiple areas, provided using a team approach.Praxis is the process of organization that involves ideation, motor planning, and execution of a purposeful action. This is a fundamental process that must be developed in order to accomplish the daily occupations of not only childhood, but will transcend through adulthood as well. Dyspraxia involves difficulty in planning and coordinating motor actions to complete a task or solve a motor problem. Dyspraxia, or weakness in this area, may lead to social withdrawal and problems integrating successfully into the work force. Deficits in praxis, fine and gross motor skills and visual integration are common in children on the autistic spectrum, and may lead to difficulties establishing relationships and with the occupations of adulthood. In the medical literature, Case-Smith and Arbesman commented that, Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. The authors suggested the predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. Further, Smith-Roley and colleagues found that services should focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information. Consistent with these findings, the authors recommended OT as well suited to affect positive change in young patients with ASD. As this patient exhibits significant difficulties with praxis (motor planning), fine motor skills, visual integration, and self-help skills, the requested OT is medically necessary and appropriate for him, at the frequency requested. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested for laparoscopic gastric banding (Lap Band) surgery for treatment of his obesity.  Findings:  The physician reviewer found that this patient meets the National Institutes of Health (NIH) guidelines for weight loss surgery. In the absence of a treatable endocrine condition, such as hypothyroidism, surgical treatment for the disease of obesity is appropriate. Sjostrom and colleagues conducted a study demonstrating that surgical weight loss procedures are the only real alternative for the treatment of morbid obesity. The authors found that the long-term outcomes of weight loss surgical procedures are far superior to non-surgical methods.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein blood testing for evaluation of the enrollee who has a history of coronary artery disease and dyslipidemia. Findings: All three physician reviewers found that the patient has a history of hyperlipidemia, hypothyroidism and coronary artery disease. She underwent advanced lipoprotein testing. The Health Plan denied reimbursement for the advanced laboratory lipoprotein testing. Per the Health Plan, the services at issue were investigational for the evaluation of this patient. Based on the records provided the patient has known coronary artery disease and hyperlipidemia. In this circumstance of known coronary disease, guidelines for the management of dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in in internal medicine with sub-specialty certification in cardiovascular disease and are 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 patient has requested authorization and coverage for Orencia 125 mg/mL. This patient is currently on CellCept with continued inflammatory arthritis symptoms. The patients provider has recommended treatment with Orencia given previous failure of CellCept, hydroxychloroquine, and prednisone. The standard steroid-sparing immunosuppressive agents for the treatment of inflammatory myositis include methotrexate and azathioprine. Although there is a lack of randomized placebo-controlled trials evaluating methotrexate in the treatment inflammatory myositis, retrospective data has demonstrated its long-term safety and efficacy with a significant increase in strength and a decline in prednisone requirements. Currently, there is a paucity of data in the medical literature to support Orencia for the treatment of inflammatory myositis. Tjarnlund and colleagues reported the effects of Orencia on disease activity and muscle biopsy features of 20 patients with dermatomyositis or polymyositis. The authors found evidence that Orencia in the treatment of patients with dermatomyositis and polymyositis can result in lower disease activity. However, the authors reported that adverse events were noted in eight patients ranging from mild to moderate. Additional studies are needed to determine whether Orencia has a clinical role in the treatment of patients with inflammatory arthritis. The patients records do not report previous treatment with methotrexate and azathioprine. For these reasons, the requested Orencia 125 mg/mL is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in rheumatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fecal DNA gene testing. Findings: Three physician reviewers found that the evidence of the impact of Cologuard on patient care or health outcomes is lacking There is no empirical data on the appropriate longitudinal follow-up for an abnormal FIT-DNA test result followed by a negative colonoscopy; there is potential for overly intensive surveillance due to clinician and patient concerns about the implications of the genetic component of the test. Health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. For these reasons, fecal DNA gene testing was not likely to have been more effective than other modalities for evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 25-year-old male with diagnoses of excessive daytime hypersomnolence and abnormal sleep latency. His clinical history suggests normal sleep habits, without sedatives or hypnotics. The patient has been provided with samples of Provigil and indicates it has been beneficial.  Polysomnography demonstrates decreased sleep latency periods, but no evidence of obstructive sleep apnea or narcolepsy. The patients request for authorization of Provigil was denied by the Health Plan citing a lack of medical necessity.Polysomnography has confirmed pathological hypersomnolence in this patient through the demonstration of abnormally short sleep latency periods. Anecdotally, the medication has been found to be effective for him. The patient had to withdraw from several classes secondary to an inability to complete assignments due to pathological sleepiness. The use of Provigil for the treatment of idiopathic hypersomnolence was endorsed by a specialist in sleep pathology. Provigil has been part of the armamentarium for treatment of idiopathic hypersomnolence in Europe since 1988. The medication is not associated with the same serious side effects as amphetamine or methylphenidote and there are no known serious drug interactions, withdrawal symptoms or symptoms of rebound sleepiness associated with its use. Peer-reviewed literature supports the use of Provigil for idiopathic hypersomnolence and one study found that 50% of subjects taking Provigil reported near normal alertness on the Epworth sleepiness scale.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient presents with neurodevelopmental abnormalities, including abnormal electroencephalography, cognitive delay, and autistic like behaviors, resulting in delay in acquisition of appropriate communication skills.  School intervention to date has resulted in some improvement, although her vocabulary and articulation skills remain significantly behind age-matched peers.  Communication skills are essential to help this patient express her needs.  The current medical evidence supports speech therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee has requested 60 visits (two times per week) of physical therapy for treatment of his cerebral palsy.  Findings:  The physician reviewer found that this patient has a lifelong condition which results in spasticity and gait impairments. Physical therapy is of demonstrated benefit for improvements in acute conditions or exacerbation of chronic conditions. There is a lack of literature support demonstrating that frequent physical therapy at this point in the management of a chronic condition will avoid progression. A literature review indicates that ongoing physical activity and exercise is indicated for maintenance (Rimmer). According to the author, For rehabilitation to play a role in the long-term maintenance and enhancement of physical functioning among persons with disabilities, increasing participation in various types of physical activity in the community must be part of the recovery and maintenance continuum. Clinical experience also does not suggest that reducing formal physical therapy efforts will result in contractures, as stretching and range of motion to maintain joint flexibility can be performed by family or other non-skilled caregivers, with periodic re-assessment and adjustment of a home program by a physical therapist. As such, the requested 60 sessions of physical therapy are not medically necessary for this patient. Based upon the documentation provided, one monthly physical therapy session including caregiver/family training for a three-month period is medically reasonable and necessary for the patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance transportation services and emergency department services he received. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the 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. The ambulance transportation services and emergency department services received were not necessary for treatment of an emergency medical condition. Patients with potentially life-threatening causes of abdominal pain should be referred to the emergency department. Indications include unstable vital signs, signs of peritonitis on abdominal exam, and concern that the abdominal pain is from a life-threatening condition. In this case, the patient did not have acute distress, his vital signs were normal, there were no signs of peritonitis, and there was no concern for life-threatening condition. The patients symptoms resolved without therapeutic intervention. In sum, there is insufficient documentation in the medical record to support the presence of an emergency condition and necessity for emergent services. Given that the patients symptoms were not acute, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date 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: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for revision of gastric bypass with adjustable gastric laparoscopic banding (Lap-Band)  for treatment of her morbid obesity.   Findings:  Three physician reviewers found that there is no peer-reviewed publication to support Lap-Band placement following failed Roux-en-Y gastric bypass surgery. Furthermore, the fact that the patient has failed one restrictive procedure indicates that she will most likely fail Lap-Band.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee requested eating disorder residential treatment center services for medical treatment of her behavioral health conditions.  Findings:  The physician reviewer found that placement in more restrictive settings is often clinically appropriate for those with serious mental illness.  In this patients case, the medical records document multiple psychiatric conditions.  She remained symptomatic throughout her course of treatment.  The following day, the patient was anxious, with tremor.  The provider noted poor eye contact and loose associations.  The treatment was reasonably expected to improve her condition, prevent a more serious episode of illness and facilitate a successful transition to a less restrictive setting.  All told, eating disorder residential treatment center services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a colonoscopy for evaluation of the enrollees polyp. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this case. The American Cancer Society guidelines for colorectal cancer screening states that in patients with average risk, colon cancer screening such as colonoscopy is recommended at age 50, and then every 10 years. These recommendations do not apply if there is a personal history of colorectal cancer or adenomatous polyps, a personal history of inflammatory bowel disease, a strong family history of colorectal cancer or polyps, or a known family history of a hereditary colorectal cancer syndrome. None of these are documented in this patients case. The joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that the recommended interval for repeat screening should be 10 years unless an adenomatous polyp or sessile serrated lesion is found, which indicates a 10-year repeat interval in this case based on the pathology results provided.  The finding of a single hamartomatous polyp does not meet the criteria for a high risk polyposis syndrome. Based on the family history and personal history information provided for this case, the colonoscopy findings, the pathology results, and the national guidelines do not support a repeat colonoscopy at five years after the first colonoscopy.  Final Result: The reviewer determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for repeated Hyalgan injections for treatment of his osteoarthritis of the knees. Findings:  The physician reviewer found that this patient had prolonged benefit from the prior Hyalgan injections. Because she is again symptomatic, the requested therapy is appropriate for treatment of the enrollees condition.