Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

A 23-year-old male has requested coverage for emergency services provided.  Findings:  The physician reviewer found that the patient sustained a flexor tendon laceration to his small finger. The patient presented to the emergency room and was informed that he would require surgery in order to restore function to the finger. He underwent a surgical consultation three days later. The patient reports that this surgeon informed him he should undergo repair of his damaged tendon within three to five days of the date of injury to prevent permanent dysfunction. The surgeon reports that he and the patient discussed the necessity for surgical repair in a timely fashion, ideally within 3-5 days for best results. The surgeon performed a left small finger flexor digitorum profundus tendon repair the next day. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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.Due to the severity and nature of the patients injury he was advised by his surgeon that he should proceed with tendon repair as soon as possible to avoid any complications and in order to restore function to his finger. A review of the literature indicates that routine tendon repairs are preferably done no later than 7 days after injury to fully restore function and that after 6 weeks primary repair and restoration of function is unlikely to be possible at all (Green, et al.). Although this patient had up to 7 days to establish care and find an in-network provider, he was advised by his treating provider that repair of his damaged tendon was required within a 3 to 5 day time frame to fully restore function to his finger and the provider recommended emergent surgical intervention. Under these circumstances, a prudent layperson would have thought his symptoms were severe enough that the absence of immediate medical attention would result in serious dysfunction of his hand. Therefore, a prudent layperson would have reasonably believed that the services provided were required on an emergent basis and would have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cosentyx for treatment of the enrollees medical condition. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  This patient previously has been treated with topical steroids, retinoids, and antifungal medications without improvement.  The records do not document treatment with a systemic agent. The Health Plan requires failure of both Humira and Stelara prior to treatment with Cosentyx, and this requirement is medically appropriate.  The patient has not met this requirement, as she has not been treated with Humira or Stelara.  The records do not document contraindication to the use of the preferred formulary medications for psoriasis.  All told, the requested medication Cosentyx is not medically indicated for the 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 dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings: The physician reviewer has 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. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with the sudden onset of severe abdominal pain with a fever and nausea. On arrival, she was found to be febrile and tachycardic. This prompted assessment for sepsis, evaluation for urinary tract infection, a search for acute surgical abdominal pathology, and treatment for systemic inflammatory response syndrome with intravenous fluids. Once an acute surgical emergency was ruled out and the patients vital signs had normalized, she was discharged. Based on the clinical documentation submitted for review, the patient received emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a bariatric surgery consultation for treatment of the enrollees abdominal pain, obesity, and diabetes mellitus. Findings: The physician reviewer found that the records document that this patient meets the current criteria for consideration of adolescent bariatric surgery, as she has a BMI of 52.8 kg/m2, which is over the threshold of 50 kg/m2. In addition, the patient also has diabetes which would allow consideration for a consultation for bariatric surgery at a BMI of 40 kg/m2 or greater based on standard published guidelines from the International Pediatric Endosurgery Group (IPEG). This patient has failed dietary efforts in the past. This recommendation is for referral to a bariatric surgeon for consultation. Given that bariatric surgery is an elective procedure requiring a multidisciplinary evaluation that can take several months to complete, it is medically supported that this patient be allowed to initiate this process now, given her high BMI. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in bariatric 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested IVIG therapy for the treatment of his Easton-Lambert Syndrome. Findings:  The physician reviewer found that this patient has a history consistent with progressive autoimmune cerebellar ataxia. Prior treatment with Rituxan and steroids have not been effective. There are no FDA approved treatments for autoimmune cerebellar ataxia. IVIG is accepted as a clinically appropriate therapy for a variety of neurologic autoimmune disorders. The clinical evidence provided shows that IVIG treatments have been successful for this patient for over two years. IVIG is medically appropriate in this setting and should be continued as treatment for this patients cerebellar ataxia.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care services provided. Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center level of care services provided were not medically necessary for treatment of the patients medical condition. Residential treatment is used for acute stabilization of psychiatric conditions and is the most restrictive form of psychiatric care available. Residential treatment is not evidence based for long-term treatment. The American Academy of Child and Adolescent Psychiatry recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports . Studies have shown that treatment outside of a residential setting are effective and as beneficial as residential treatment center programs . In this case, at the time of admission his overall level of anxiety was low, and he denied any thoughts of self-harm. The records indicate the patient was open in his individual and group therapy sessions throughout his stay. He was not displaying any significant or severe behavioral problems after admission. Although the patient does need more treatment to further improve his social functioning, mood, anxiety, family relationships, and behavioral issues, this did not require the restrictiveness of a residential treatment facility. In sum, the patient could have been treated in a less restrictive setting during the dates in dispute. As such, the residential treatment provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) is a utilization system to assess level of care needs for children and adolescents receiving psychiatric care. With regards to risk of harm, the records support a score of 1. With regards to comorbidity, the records support a score of 1. In terms of level of stress of the recovery environment, the records supported a score of 3. There was evidence of moderate stress in the patients home, as she was diagnosed with reactive attachment disorder. With regards to level of support of the recovery environment, the records support a score of 3. In terms of resiliency and treatment history, the records support a score of 1. With regards to acceptance and engagement of the patient, the records support a score of 2. In terms of acceptance and engagement of the caretaker, the records support a score of 2. The total equals 14, with no extreme outliers, indicating that the appropriate level of care was outpatient care. Thus, the patient could have been treated in a less restrictive environment. Therefore, services provided by treatment facility were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female who is status post a motor vehicle accident with neck and arm pain due to disc bulging, facet arthropathy and occipital headaches. She is being treated with the medication Lyrica in addition to Tylenol with Codeine, Naprosyn and occipital nerve blocks. At issue is whether Lyrica is medically necessary for treatment of the patients medical condition.At this time Lyrica has been studied and has been approved by the Food and Drug Administration in the use of diabetic neuropathy and post hepatic neuralgic pain. Lyrica has not been well studied or proven effective or medically appropriate for non-specific neck pain or whiplash injuries status post a motor vehicle accident. As such, there is insufficient evidence supporting the use of Lyrica in this clinical setting. There are other medications/modalities available for the management of this patients pain. Accordingly, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections.Thoracic outlet syndrome is a difficult condition to diagnose, principally arising from an absence of other causes for arm/shoulder pain as well as typical symptoms and provocative physical maneuvers. In an effort to provide diagnostic accuracy, selective injection of the scalene muscles as well as the pectoralis minor muscle with local anesthetics has been useful in some cases. Guided injection of Botox has also been investigated as a means of both diagnosis and treatment. A study by Salhan and colleagues suggests improvement with Botox injections, notably from a center well-established in the treatment of thoracic outlet syndrome. Botox injections are generally safe with few reported complications. The procedure should be viewed as medically necessary for diagnostic as well as therapeutic purposes. In this case, the patient has been diagnosed with thoracic outlet syndrome. There is sufficient support for the requested services in this clinical setting. Therefore, Botox injections are medically necessary for the treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollees cystic fibrosis and pancreatitis. Findings:  The physician reviewers found that cystic fibrosis is a multisystem disease affecting epithelia of multiple organs including the exocrine pancreas. Given the extreme nature of the patients pancreatic disease, the hereditary pancreatitis panel was used to rule out other potential gene changes in addition to CFTR mutations. Current guidelines recommend sweat chloride testing be done on patients with signs, symptoms or a family history concerning for cystic fibrosis. For patient with sweat chloride testing between 30-59 mmol/L, CFTR mutation testing is recommended. The results of this testing could help determine the patients eligibility for total pancreatectomy with islet autotransplantation (TPIAT). For these reasons, the CFTR portion of the hereditary pancreatitis panel was likely to be more beneficial for evaluation of this patients cystic fibrosis than any available testing, and the remaining portion of the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in pediatrics with sub-specialty certifications in genetics and neurodevelopmental behavioral pediatrics and 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right bipolar ablation. Findings:  The physician reviewer found that based on the medical evidence regarding radiofrequency ablation of the sacroiliac joint, there is wide variation in reported efficacy and lack of uniformity in how the procedure is conducted. A study characterized the evidence supporting radiofrequency ablation of the sacroiliac joint nerves as limited, with large numbers of case series with large false positive results and limited efficacy.  Another study conducted a systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions and found limited effectiveness.  In sum, the superior efficacy of the requested right bipolar ablation has not been established.Final Result: The reviewers  2 of 3 determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer s are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for DecisionDx  Melanoma genetic testing. The enrollee was diagnosed with cutaneous melanoma after a biopsy of a lesion on his left lateral mid-back. The DecisionDxMelanoma genetic testing report noted it was Class 1, subclass 1A. The enrollees dermatologist believes the results from the DecisionDxMelanoma testing, in conjunction with other clinical assessments, help identify a persons risk profile, which aids in optimal treatment planning. Literature describes the DecisionDx-Melanoma gene panel as a diagnostic not currently recommended by professional societies as part of standard treatment. This diagnostic requires additional analysis and research regarding the sensitivity and specificity of the test, conducted in individuals who are representative of the general primary melanoma population. Additionally, interpretation of the results is of critical importance. Clinicians may suggest that those for whom test results predict a high risk for metastasis undergo more frequent clinical evaluations and surveillance imaging; particularly those who have negative sentinel lymph node biopsies. However, in settings in which adjuvant therapies are either contraindicated or not available, this categorization may increase anxiety without realizing any true benefit. Those with a Class 2 Gene Expression Profile (GEP) score have been shown to be 1.5 times more likely to have a poor outcome, which means these individuals could receive life-saving preventive therapies. Staging is determined by the tumor, node, and metastasis (TMN) system developed professional societies.  Criteria include microstaging of the primary melanoma and pathologic information about the regional lymph nodes after partial or complete lymphadenectomy. Survival and recurrence rates for melanoma follow the pathologic stages set forth by the professional societies. This data is used for follow-up treatment planningFinal Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology 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.