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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 26 sessions of physical therapy over 26 weeks for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. Close therapist supervision and guidance can be important in the initial stages of a rehabilitation program for partial rotator cuff tears and other shoulder conditions, but long-term skilled physical therapy, including supervised exercises, modalities and formal manual therapies/modalities, is not of proven benefit in this clinical setting. As range of motion and strength are restored and the patient becomes accustomed to the exercises, the patient can be transitioned to an independent program. Although the patient has persistent symptoms, further physical therapy is not expected to favorably impact the clinical or functional outcomes or course. In this case, the records do not support prolonged skilled exercise supervision. There is also no proven marginally significant benefit of formal manual therapy or other formal passive palliative modalities over palliative measures that can be applied independently. The medical evidence does not support the requested services in this patients case. All told, the requested 26 sessions of physical therapy over 26 weeks are not medically necessary for the treatment of this patient. Final Result: The physician 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 physician 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 has requested authorization and coverage for magnetic resonance imaging (MRI) of the right knee. She presents with complaints of persistent right knee pain and swelling with startup pain and stiffness. Clinical examination findings revealed mild loss of range of motion, trace effusion, patellofemoral crepitus, and negative ligament and meniscal signs. The patient was treated with activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), and a home exercise program. X-rays demonstrated mild degenerative joint disease and no fracture. The providers impression included a probable bone bruise. Current evidence-based medical guidelines and peer-reviewed literature do not support MRI in this clinical setting. The American College of Radiology (ACR) recommends MRI for adults with a history of fall when x-rays do not reveal evidence of fracture and there is clinical suspicion of internal derangement. MRI is considered the optimal imaging modality for identifying meniscal, ligament, chondral, and non-displaced bone injuries about the knee. In the medical literature, Parent and colleagues recommended evaluating knee pain in older patients with a comprehensive medical questionnaire, thorough physical examination, and radiographs. Conservative non-pharmacologic and pharmacologic therapies should be attempted and allowed sufficient time to take effect before considering further evaluation with MRI. All told, the requested MRI of the right knee is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary: This is a patient with diabetes, hyperlipidemia, hypertension and a fatty liver, that was being followed by an internist, his primary care physician (PCP). The PCP prescribed orlistat 120 mg capsules to be taken three times a day (TID). The orlistat prescription was refilled monthly in 2007 through May of 2019. The patient requested to resume orlistat due to hard stools after stopping Orlistat. The PCP recommended that he should take over the counter stool softeners for the hard stools, as orlistat 120mg taken three times a day, can cause liver toxicity. At issue is whether the requested medication Orlistat (Xenical) 120 mg capsules, is medically necessary to treat the patients medical condition. According to medical records, the patient was started on orlistat in 2007 since, diet and exercise for weight loss, had not worked. Despite taking orlistat (Xenical) for over 10 years duration, the patients body weight has not significantly changed. The physician recommended an over the counter stool softener (Colace). Currently, orlistat (Xenical) is approved by the Federal Drug Administration (FDA) for the following indications: obesity with a body mass index (BMI) of over 30 kilograms per meter squared (kg/m2), body mass index great than 27 kg/m2 and presence of risk factors including hypertension, diabetes mellitus, and dyslipidemias. It is only effective as an adjunct to caloric restriction, increased physical activity, and behavioral modification. According to the medical records including correspondence from the patient, the main purpose for taking orlistat in this case was for constipation. Orlistat is not FDA approved for constipation. Based on the FDA recommendations, and documentation in the medical records provided, the requested medication is not indicated for this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested an MRI of the lumbar spine for an evaluation of her back pain. Findings:  The physician reviewer found that the clinical documentation provided for review is limited, and does not include a neurological examination. There is no indication of a recent trial of conservative therapy or referral to a neurologist or orthopedic or neurological surgeon. The need for MR imaging of the lumbar spine is not apparent from the evidence submitted.
Appeal type: Urgent Care
Decision: Upheld

An 80-year-old female enrollee has requested coverage for past emergency services. Findings:  The physician reviewer found that the patient presented to the emergency room with complaints of right thigh and hip pain for the previous two weeks. The patient described her pain to be worse at night and to have been worse for the previous two nights. The patients pain level was documented as mild. The patient denied a history of a fall or trauma to that hip and noted that she was able to walk up and down stairs without trouble. The physical examination revealed mild tenderness to palpation over the lateral right thigh/hip area with normal range of motion of the hip and no edema. X-rays showed mild osteoarthritis of the right hip, and did not show evidence of a fracture, dislocation or tumor. The patient was diagnosed with bursitis and discharged with instructions to follow-up with her primary care physician in two to three days.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.The patients thigh and hip discomfort had been present for approximately two weeks, there was no event to suggest that the hip had been broken, there was no evidence of infection and the patients pain was described as mild. Additionally, it was reported that the patients pain did not restrict activity, such as navigating stairs. All told, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health and therefore would not have sought immediate medical attention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) infusions with Gamunex-C. Based on the patients medical history of recurrent sinus infections requiring antibiotics on a monthly basis in the context of low IgM levels, treatment with IVIG replacement therapy is appropriate. IgM levels are considered deficient for an adult when the value is below 30, and this patient had two documented levels that are considered deficient. Although her response to pneumococcal vaccination has been appropriate, IgM deficient patients have demonstrated normal polysaccharide vaccine responses and yet are unable to mount a defensive response to sinus and pulmonary infections. For these reasons, the requested IVIG infusions with Gamunex-C are medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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

The patient is a 12-year-old female with a long history of severe anxiety, phobias and obsessive-compulsive symptoms. She has received treatment over the years with multiple combinations of medications and therapies. The patient had pervasive symptoms, which severely affected the patients normal social growth and development. A SPECT brain study was performed to clarify her diagnosis and offer treatment suggestions. The Health Plan has denied reimbursement for the SPECT scan at issue on the basis it was not medically necessary for evaluation of the patients medical condition.Review of the relevant medical literature reveals there is growing support for use of SPECT scans for diagnosis and management of psychiatric disorders. There is data demonstrating the efficacy of SPECT scanning in selected cases. Based upon the information provided, it appears the SPECT scan was of clinical value in the case of this patient as the results of the SPECT scan revealed the need for alternative therapy, which was ultimately successful. Therefore, I have determined the SPECT scan at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Based on the documentation presented, the patient meets the criteria for medical necessity at the IOP level of care. Using the American Society of Addiction Medicine (ASAM) criteria for IOP, on dimension 1, the patient demonstrated a minimal risk of severe withdrawal as evidenced by multiple providers notes from stating that he was not experiencing withdrawal symptoms. On ASAM dimension 2, the patient demonstrated a minimal risk for biomedical conditions as evidenced by multiple entries from stating that he was feeling physically okay with adequate sleep and appetite. On ASAM dimension 3, the patient demonstrated mild severity for emotional or behavioral conditions as his depression and anxiety that ranged from a four out of 10, to as high as a seven out of 10, with no evidence of suicidal ideation, intent, or plan. On ASAM dimension 4, the patient demonstrated variable treatment engagement that required a structured program as evidenced by the providers notes. The provider noted the patient expressed anxiety about transitioning out of IOP. The notes state the patient appeared disengaged. The patient began sharing in the group more openly. He struggled to imagine living a sober life. The patient displayed a negative attitude with sarcastic comments in group therapy. On ASAM on dimension 5, the patient demonstrated a high likelihood of relapse without the structured program as evidenced by staff documentation of his craving for alcohol as six out of 10. The records report the patients cravings reached an intensity of seven out of 10. On ASAM dimension 6, the patient demonstrated an unsupportive environment as evidenced by his lack of a sponsor and a lack of a sober social network as reported in the documentation. All told, the records support the medical necessity of the IOP services for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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: The patient has requested reimbursement for anesthesia services during a colonoscopy. The American Society for Gastrointestinal Endoscopists (ASGE) guidelines for sedation and anesthesia in gastrointestinal endoscopy do not support the use of monitored anesthesia care in patients without significant health conditions or airway concerns. The guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, as in this patients clinical setting. The standard of care includes minimal or moderate sedation safely delivered by endoscopists for patients who are ASA Classes I, II, or III. The review study performed found that the use of deeper levels of anesthesia was associated with a 13% increase in complications including bowel perforations. In this case, the patient underwent a routine colonoscopy for colonic polyps and evaluation of suspected diverticulitis. The patient was given an ASA classification score of II and there is no evidence in the anesthesia record that the patient had an airway examination or that he presented with a difficult airway. There is no documentation of previous difficulties or problems with anesthesia. There is no reported history of issues with alcohol or substance abuse, or a history of smoking. The patient did not have any significant heart, lung, kidney, or liver disease. Given these findings, the anesthesia services during a colonoscopy were not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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

The parent of a 14-year-old male enrollee has requested  for acute inpatient psychiatric for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the degree of improvement was not sufficient for discharge. The patient had not maintained this improvement for a reasonable period of time nor had he internalized his behavioral gains. He continued to need inpatient hospital staff supervision around the clock.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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 overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology 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 diagnostic radiology 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 diagnostic radiology 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 62-year-old female enrollee has requested for resection of recurrent endometrial stromal sarcoma for treatment of her recurrent endometrial stromal sarcoma.  Findings:  The physician reviewer found that several studies and case reports have shown benefits of major debulking, also known as cytoreduction surgery, in treating very difficult cases such as in this patients situation. All told, the requested major debulking surgery of this patients recurrent sarcoma is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi 400 mg for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that pursuant to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. The patients prior treatment status is not clearly documented in the records provided. Regardless of his treatment history, Sovaldi should not be used as monotherapy. The guidelines recommend either Sovaldi or Daklinza for 12 weeks or Sovaldi, peg-interferon and ribavirin for 12 weeks. This recommendation is based on the ALLY-3 and EUCUP trials.  The BOSON trial demonstrated efficacy for Sovaldi with peg-interferon and ribavirin (Foster et al). For these reasons, medical necessity for monotherapy with Sovaldi 400 mg has not been established.  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 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.