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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The 3 physician reviewers found that In the medical literature, genetic testing for medication guidance has not been demonstrated to result in improved health outcomes when used to direct treatment. Sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available. Genetic testing may not be reporting relevant clinical information. Although there are some circumstances that genetic testing may be indicated, there is a lack of scientific data supporting the use of the genetic testing performed in this case. Thus, the genotype testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Urgent Care
Decision: Overturned

A 61-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that the patient was suffering from an acute injury (24-48 hours) involving severe and increasingly worse pain of a nature that would lead a patient to make a reasoned decision to seek immediate care due to potential jeopardy to his health or function.  According to the patient, he was unable to drive the distance required to be seen at the Kaiser Emergency Center and elected to go to a closer hospital for evaluation of his worsening leg pain and swelling.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a peripherally inserted central catheter (PICC). In this case, the patient was being treated appropriately with intravenous Invanz for a complicated urinary tract infection with extended-spectrum beta lactamase producing Escherichia coli. Per the records, seven additional days of intravenous antibiotics were recommended after the inpatient hospitalization from late October 2017.  Subsequently, she had another urine culture that was positive for extended-spectrum beta lactamase producing Escherichia coli and required treatment with intravenous antibiotics as recommended. The bacteria were sensitive to Invanz, which can be administered intramuscularly or in a peripherally placed line.  There is no documentation to support that she requires a PICC line to be placed for administration of this medication.  Furthermore, there is no clear documentation to support that she has been evaluated by a medical provider who has ordered a PICC line to be placed. Therefore, the requested PICC line is not medically necessary for the 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 internal 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for general anesthesia. Marinho and colleagues report that comprehensive dental care under general anesthesia composes an integral part of special care dentistry and may be safely provided in a hospital setting, in both private and public sectors. The authors further note that general anesthesia is considered as an alternative option to facilitate treatment for uncooperative patients who require invasive dental interventions, with multiple dental extractions and restorations being the most frequently performed procedures. Ciftci and Yazicioglu report that medical and mental conditions affect dental treatment modalities. In this clinical setting, treatment of the patient in a surgical facility under general anesthesia is medically indicated. Therefore, general anesthesia is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CA125 cancer screening test.  Findings:  The physician reviewer found that the CA125 serum test is elevated in approximately 50% cases of ovarian cancer cases. The CA125 serum test is sensitive but not specific since it can also be elevated in other non-malignant conditions. However, there is significant literature on the use of CA125 in detecting ovarian cancer. Although CA125 is not the sole criterion on which to decide surgery, a pre-operative level is necessary if a patients pathology shows cancer. In addition, the post-treatment surveillance of ovarian cancer patients typically involves physical and pelvic examinations, CA125 testing at the time of clinic visits, and imaging studies as clinically indicated. All told, the requested CA125 cancer screening test is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any residential treatment center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient underwent management for alcohol withdrawal. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient did not have biomedical conditions and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of depression and social anxiety. The patient endorsed suicidal ideation, with a history of a suicide attempt via overdose. The patient reported using substances to function, and the records noted that the patient was experiencing night terrors. The patients mental status was stable enough to permit participation. He demonstrated a repeated inability to control his impulses to use alcohol, and he was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient was admitted voluntarily for treatment, reporting that he was tired of his substance use and of not being able to function. The patient reported feeling depressed with suicidal thoughts due to hopelessness about his addiction. He had been using substances despite being in outpatient treatment. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care. For dimension 5, the patient relapsed despite being in an outpatient program following five months of sobriety. He had a history of one prior suicide attempt and reported suicidal thoughts and feelings of hopelessness. Despite recent, active, participation in treatment at a less intensive level of care, the patient continued to use drugs with imminent serious consequences and was at high risk of continued substance use in the absence of close 24-hour monitoring and structured treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute inpatient rehabilitation services including occupational therapy, physical therapy, and recreational therapy. This patient sustained severe trauma due to a motor vehicle accident resulting in major injuries to both of her lower limbs. The accident may have prolonged effects on the patients health, function and well-being, including in the social and vocational domains (Solvang, et al.). The records provided for review document that the patient  has undergone extensive inpatient rehabilitation. However, the patients progress suggests that she has largely plateaued with respect to her functionality given her ongoing bilateral leg non-weightbearing restrictions, pain, and endurance issues. The patient is able to transfer with a slide board at a supervision level and is independent propelling a manual wheelchair. She continues to require some physical assistance for her lower body self-care activities. The patients rehabilitation goals focus on optimizing her compensatory skills at a wheelchair level until her bones have sufficiently healed enough for weight bearing activities. These compensatory skills goals can be further pursued at the skilled nursing facility (SNF) or in the community. There is a lack of documentation of intensive rehabilitation needs, need for close physician supervision, or need for 24-hour per day rehabilitation nursing availability to support an indication for acute inpatient rehabilitation facility services including occupational and physical therapies (Mayer, et al.). Treatment with recreational therapy can be a helpful adjunct in the convalescence of a patient who has faced significant trauma, but there is a paucity of data demonstrating that this type of intervention is medically necessary in this clinical setting. For recreational therapy, patient peers do not have to be the same or similar age to have a positive influence on the patient. All told, the requested acute inpatient rehabilitation services including occupational therapy, physical therapy, and recreational therapy are 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for two sessions of somatic therapy per week.At issue in this case is whether the two sessions of somatic therapy per week are medically necessary to treat the patients medical condition. as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the of the patient, treating physician, or other health care provider.The literature supports somatic therapy at least once weekly and up to twice a week for an indefinite duration of treatment. Given this patients past medical history, it would be prudent to provider a more intensive outpatient treatment, which can be tapered down over time, to prevent any further decompensation and help her to regain her baseline level of functioning. Since the trauma symptoms are the ones triggering her suicidality and preventing her from being able to return to work, it is imperative that these are addressed specifically through intensive outpatient therapy. In this patients case, two sessions of somatic therapy per week are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. For these reasons, two sessions of somatic therapy per week are medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee requested Percocet 10/325 for treatment of his medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support Percocet 10/325 in this clinical setting.  The standard of care for chronic pain associated with piriformis syndrome is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy and injections to help reduce pain.  Baron and McDonald reported that high-dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  All told, Percocet 10/325 is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy. There is a lack of high quality clinical outcomes or expert consensus national guidelines supporting the use of the proton beam radiation therapy for management of this patients stage IV kidney cancer. The records did not indicate oligometastatic disease. In this clinical setting, dose escalated radiotherapy is not proven to yield superior survival outcomes. Additionally, the submitted proton/photon plan comparison showed that the photon-based treatment plan could have been delivered with an acceptable rate of safety and efficacy, even if dose escalation were required. The records did not show any extenuating circumstances supporting the service at issue, such as prior receipt of external beam radiation to an overlapping field or the presence of a comorbid or genetic condition placing the patient at increased risk for normal tissue toxicity. Therefore, proton beam radiation therapy was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found that proton beam radiation therapy was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 reviewers 1, 2, and 3 are board certified in radiation oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a repeat biopsy. The 2018 NCCN guidelines on prostate cancer indicate that a repeat biopsy should be considered if the prostate exam changes, if a multiparametric MRI (mpMRI) indicates a more aggressive disease or if the PSA value changes. The guidelines further recommend monitoring of diagnosed prostate cancer with PSA testing every 3-6 months accompanied by digital rectal exams. If there is new or worsening bone pain, additionally a bone scan is recommended at detection and every 6-12 months. Here, the patient was diagnosed with relatively low-risk (Gleason 3+3) prostate cancer. Documentation does not indicate an increase in PSA that might warrant a biopsy. Records do not show that the patient has had an mpMRI, nor are there any other indicators that this patient has an aggressive form of prostate cancer. There are no recent prostate exam findings that indicate a noteworthy change in the patients condition. Lastly, there is no isolated mass that might be targeted for a second biopsy. Therefore, a repeat biopsy is not medically necessary for this patient at this time.Final Result: The reviewer determined that the requested service 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 urology 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 lumbar spinal fusion for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient presents with persistent and worsening low back pain with functional difficulty in work and daily activities. Detailed evidence of at least six months of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted.  However, there are no clinical objective findings of nerve root compromise correlated with imaging evidence of degenerative disc disease. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion or imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, the requested lumbar spinal fusion is not medically indicated for the 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 26-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that it is true that more frequent than annual screening MRI is generally not indicated, even in high-risk patients. However, the MRI requested in this case is for problem solving and monitoring of a specific area seen within the breast that can only be evaluated with a repeat MRI. In this particular setting, physical exam, standard mammography and ultrasound are not sufficient exams to determine if a biopsy is necessary. The dense tissue on mammography and the equivocal findings on ultrasound attest to the limitations of these standard techniques. The lesion in question is best seen on MRI and given the patients strong family history, careful monitoring is indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomographic angiography and computed tomographic angiography chest for evaluation of the enrollee, who has a history of hyperlipidemia and glucose intolerance. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based on the records provided, the patient presented with increased coronary risk on statin therapy and without documented symptoms or physical examination abnormalities suggestive of coronary ischemia.  In this circumstance, screening coronary computed tomography angiography is not medically necessary and is not considered standard accepted practice in the medical community. The decision to treat with a statin medication has already been made based on risk factors.  Current guidelines endorsed by several national organizations also do not recommend coronary computed tomography angiography as a screening test in this setting. Final Result: The reviewer determined that the services at issue were 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 cardiovascular disease 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.