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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services received from 7/26/16 through 8/1/16.Findings:  The physician reviewer found that the patient sustained bilateral ankle fractures and had been immobilized with non-weight bearing restrictions.  She had undergone inpatient rehabilitation and had progressed as of 7/26/16 to a functional level where further care could have been provided in a lower level of care.  At that time, she required supervision for her self-care and household level mobility at a wheelchair level. There were no ongoing goals or needs requiring inpatient level rehabilitation, as further rehabilitation goals were precluded by her bilateral lower limb non-weight bearing status. The medical literature notes, there is little evidence for rehabilitation interventions during the immobilization period following ankle fractures, outside of optimizing general function, like from a wheelchair level.  In general, the marginal benefits of supervised exercise in the setting of ankle fractures are questionable.  There were no complex wounds or other skilled needs requiring ongoing inpatient level of care.  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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old non-obese male who has obstructive sleep apnea/hypopnea syndrome diagnosed based on excessive daytime sleepiness associated with choking. Apnea hypopnea index (AHI) is less than six. In addition, the patient has a history of gastroesophageal reflux disease (GERD). The patient reports he has taken Provigil with therapeutic benefit. The information provided does not include definite defined sleep latency, history of aftercare following the polysomnography or history of endoscopic evaluation of GERD.The patient has requested coverage for continued use of Provigil. The Health Plan has denied the request on the basis Provigil is not medically necessary for treatment of the patients condition.The patients diagnosis is not well defined. The polysomnography study does not reach the threshold sufficient for a diagnosis of obstructive sleep apnea requiring treatment. Daytime sleepiness is not well established. There is no evidence of a sleep latency test, nor is the clinical history sufficient to determine if the patient is clearly excessively sleepy. The presentation with choking, plus the patients history of known GERD, challenges this diagnosis. The alternative diagnosis may be severe GERD.Notwithstanding the information set forth above, Provigil has proven clinically effective for the patient in terms of reduction of daytime sleepiness. This, in fact, is of clinical importance. If evidence is obtained that shows the patient does not have an alternative diagnosis and treatment (e.g., effective management of GERD) or if there is evidence of failed CPAP after clear use of alternative sleep hygiene interventions, then use of Provigil would be medically appropriate and the patients request should be reconsidered. However, at this time I have determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of breast implants without an en bloc by a plastic surgeon who utilizes microsurgery techniques and total capsulectomy; or in the alternative, removal of breast implants generally with total capsulectomy. The patients symptoms include insomnia and brain fog, fatigue, joint pain and left breast pain, as well as numbness in the extremities. However, the records provided for review do not include complaints referring to physical complications of her breast augmentation. Magnetic resonance imaging (MRI) showed intact bilateral subglandular silicone implants. The left implant showed a fold and a trace of peri-implant fluid on the left, suggestive of a left capsular contracture. There is no history of the breast augmentation or physical examination describing capsular contracture. Researchers stated that, autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. However, Balk and colleagues noted that the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. This patient presents with generalized complaints. Based on the available documentation, an association of the patients symptoms with the presence of silicone gel implants has not been established. The patient requests authorization for removal of her breast implants with capsulectomies. The medical information reviewed and peer-reviewed medical literature do not support removal of the patients silicone gel breast implants, with or without capsulectomies. Accordingly, the requested removal of breast implants without an en bloc by a plastic surgeon who utilizes microsurgery techniques and total capsulectomy or removal of breast implants generally with total capsulectomy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that regarding her recovery environment, the patient has a moderately stressful environment, and the records support a score of 3. The patients husband is supportive of the patient. The patients mother died six months prior to admission, which she reports was a distressful circumstance. In terms of level of support, the records support a score of 2.  The patient has a supportive environment, as her husband is supportive. Regarding treatment history, the documentation supports a score of 3.  The patient has had limited prior treatment. She participated in Alcoholics Anonymous, and this was unsuccessful to curb her drinking. In terms of engagement and recovery status, the records support a score of 3.  The patient appears to want to engage in treatment and desires to recover. However, notes report that she is in the contemplative stage and may lack confidence to change despite  intentions to do so.  She is able to develop a positive relationship with her providers, but appears to have some uncertainty in acceptance of her illness. Therefore, the records support a total score of 20.  Based on these criteria, the patient meets criteria for a partial hospitalization program. All told, residential treatment center services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Findings:  The physician reviewer found that a female enrollee has requested reimbursement for the breast magnetic resonance imaging (MRI). Current guidelines in high risk women have just been released, and reiterated the rationale and need for aggressive breast cancer screening in high risk women, which includes breast MRI. However, this patient does not meet the described criteria. Studies demonstrate a low yield in the detection of breast cancer in a patient with a palpable abnormality in the setting of a negative mammogram and ultrasound. Most commonly, clinical follow-up is recommended, and biopsy of the palpable finding, if suspicion of breast cancer exists on a clinical basis. For these reasons, the breast MRI was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the breast MRI was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the diagnostic procedure at issue was 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:  One reviewer is board certified in diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology and is 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services.  Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a rapidly progressive symptom complex with sore throat, severe right ear pain, and bloody drainage from the ear canal.  A prudent layperson would have considered this an acute emergency for several reasons. First, the intense pain rating of 10/10 is often associated with severe middle ear infections. Second, the patient experienced bloody drainage from the right ear. Third, the loss of hearing associated with purulent otitis media and tympanic membrane rupture would be very concerning to the prudent layperson for permanent hearing loss. In this clinical setting, the patients ear function was at risk for further deterioration, and had the potential for more damage if the infection was not treated in a timely manner.  Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the emergency department services at issue met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. 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

A 22-year-old female enrollee has requested inpatient psychiatric hospitalization services for treatment of her major depressive disorder and bulimia nervosa.  Findings:  The physician reviewer found that clinical guidelines and patient placement criteria have been developed to assist with complicated determinations as with this patient, and it is the task of the providers working directly with the patient to interpret and apply these tools. In this patients case, discharge on the said date would have been premature and inconsistent with good medical practice as the patient was endorsing physical symptoms and suicidal ideation with plan. On the said date, in context of continued suicidality, the patients antipsychotic medication was changed. Shortly thereafter, the patients chronic suicidality, enduring negative schemas, and somatic preoccupation were demanding of treatment but no longer acute in nature. She was better able to contain her emotions while eating up to 80% of meals and tolerating her psychotropic medications in the absence of any reported symptoms of alcohol withdrawal. In conclusion, the acute inpatient psychiatric services were medically necessary during the said time frame for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for negative pressure wound therapy for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The medical literature has demonstrated that negative pressure wound therapy improves time to closure, decreases hospital days, improves control of wound drainage, and decreases pain.  This treatment has become the standard management for open wounds.  The services at issue were for this high-risk, immunocompromised patient with a large, infected wound.  In sum, negative pressure wound therapy was likely to have been more efficacious than other treatment options.Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in surgery 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: Upheld

The parent of a six-year-old male enrollee has requested aquatic physical therapy for treatment of the enrollees congenital hydrocephalus. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested therapy. The medical literature lacks sufficient evidence and a lack of consensus to make a recommendation on the effectiveness of aquatic physical therapy combined with land-based physical therapy in children with acquired neurological impairments. McManus and colleagues noted in a case series report of children with developmental issues (cerebral palsy, juvenile idiopathic arthritis, Prader-Willi syndrome) showing clinical improvement in functional mobility, walking endurance, range of motion, muscle strength and pain reduction. However, there were no individuals in the case series with congenital hydrocephalus. Aquatic therapy is not a standard of care modality in this setting and is not considered medically necessary in this setting.  Thus, the aquatic therapy in this case is not a medically indicated form of treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested transcranial magnetic stimulation therapy (TMS) therapy for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The American Psychiatric Association has endorsed TMS in its current clinical practice guideline for the treatment of individuals with depression.  In this case, the patient was enduring an acute major depressive episode that was causing significant morbidity and functional impairment.  She had pursued other standard therapies and continued to experience symptoms.  There is sufficient support for the services at issue in this patients case.  Per the submitted records, TMS was likely to improve the patients condition and prevent a more serious health condition.  All told, TMS therapy was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested inpatient hospital stay for treatment of her pancreatitis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. According to the Society for Surgery of the Alimentary Tract (SSAT), The severity of acute pancreatitis ranges from edema to necrosis of the gland. The edematous form of the disease occurs in about 80-85% of patients and is self-limited The SSAT also states that Patients with mild pancreatitis usually experience resolution of their pain within 24-48 hours after a regimen of no oral intake, narcotics for pain relief, and intravenous fluids. Once oral intake is tolerated, patients can be discharged from the hospital. Moreover, a CT scan helps determine the outlook or prognosis. If the scan indicates that the pancreas is only mildly swollen, the prognosis is excellent (Freedman). The patients presentation of pancreatitis was mild without radiographic evidence of necrosis or obstructing stones. She rapidly improved, both clinically and biochemically, tolerating oral feedings within 48 hours of ER arrival. These indicators of recovery fail to support medical necessity for prolonged hospitalization beyond the patients initial observation period. Therefore, the medical necessity of the services at issue has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

35-year-old female enrollee has requested mental health outpatient treatments at a frequency of three times per week for treatment of her post-traumatic stress disorder and depression. Findings:  The physician reviewer found current information from the therapist provides a GAF of 55, which indicates moderate impairment in functioning.  Goals of treatment appear longstanding, such as resolving past childhood abuse, resolving causes of depression, managing emotions constructively and building healthy social and intimate relationships.  The patient has contracted for safety.  Psychosocial and environmental problems were also identified as inhibiting the patients recovery, including inadequate social support.  Based on the identified treatment goals and a current GAF of 55, treatment goals could be accomplished within two sessions per week. Per the submitted records, mental health outpatient treatments at a frequency of two times per week from the date in question onward were and are medically indicated. However, mental health outpatient treatments at a frequency of three times per week during this time were not and are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heart surgery, transcatheter closure of a left atrial appendage (Watchman procedure) for treatment of the enrollees paroxysmal atrial fibrillation. Findings: All three physician reviewers found that in this patients circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting a small bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The Watchman device has been demonstrated to be non-inferior compared with warfarin. In addition, device placement in these trials had a high rate of significant complications (3.7-7.7%) due to pericardial effusion and procedural stroke related to thromboembolism or air embolization. The U.S. Food and Drug Administration (FDA) approved the device based on a more recent trial (PREVAIL) with lower complication rates. However, longer term follow up of that trial demonstrated an additional eight strokes, all in the arm that received the Watchman device, calling into question its long-term efficacy. Taking these additional data into account, the Watchman device failed to demonstrate non-inferiority to warfarin. Therefore, the Watchman procedure remains controversial especially in patients who are tolerating anticoagulation without bleeding side effects, without strokes and with low CHADS score, such as this patient under review. Final Result: The reviewers determined that the requested surgery is 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.