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

The parent of a four-year-old male enrollee has requested speech therapy services two hours per day, five days per week to include therapeutic services for the use of a non-speech generating device, including programming and modification for the treatment of the enrollees autism. Findings:  The physician reviewer found that speech therapy techniques can be successful in inducing the autistic child to speak and the crucial role of the speech therapist is outlined in the monograph by the American Speech-Language-Hearing Association Ad Hoc Committee on Autism Spectrum Disorders (Goldstein). Turner and colleagues conducted a controlled study of autistic children who did or did not receive speech in early childhood, and concluded that by the age of nine, the speech therapy group was far superior in language compared with the control group. The controlled study by Goorhuis-Brouwer and Knijff reports that children with significant cognitive impairment will benefit from speech therapy. Thus, the literature strongly supports the medical necessity of speech therapy in the autistic child. However, there is no evidence demonstrating that daily speech therapy is any more effective than therapy provided at a frequency of three times per week.  The frequency of therapy authorized by the Health Plan is medically appropriate in this setting. The need for daily speech therapy (for a total of 10 hours per week) is not established as it is not likely to yield greater results than less frequent therapy. Furthermore, with regard to the request for therapeutic services for the use of a non-speech generating device (or augmentative and alternative communication device), there is a paucity of literature in support of such devices. Currently, there is a lack of evidence demonstrating the efficacy of this technology for patients with autism. In addition, the clinical findings in this case do not support the benefit of a non-speech generating device for this patient at this time. The patient is not currently functioning at a level that will allow him to benefit from use of the proposed device. Thus, the medical necessity for therapeutic services for the use of a non-speech generating device has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested for replacement of breast implants for treatment of her capsular contracture of breast implants. Findings:  The physician reviewer found that the medical records noted grade III capsular contracture, the reviewed materials support the presence of grade IV capsular contracture.  In this patients case, the Health Plan has agreed to provide coverage for breast implant removal.  However, replacement of these implants, which were originally placed for cosmetic reasons, with new breast implants is not medically necessary. There is no evidence demonstrating that implant removal would leave her with abnormal appearing breasts.  The documentation fails to demonstrate the medical necessity of the requested replacement of breast implants.  All told, the requested replacement of breast implants is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee requested authorization and coverage for a septoplasty. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees bilateral nasal obstruction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested Soma for treatment of her chronic pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Soma is a muscle relaxant with more addictive and abusive properties than opioids. Additionally, Soma is a centrally acting muscle relaxant associated with a high risk of dependence and tolerance; therefore long-term administration is not recommended (Fishman). Baron and McDonald reported that high dose opiates and centrally acting muscle relaxants might contribute to sensitization via hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of opioids and other medications such as Soma for a chronic medical condition reported a significant decrease in pain at the end of the study, further supporting the theory of hyperalgesia. It would therefore, be in the best interest of the patient to wean off the Soma. Moreover, centrally-acting and addictive muscle relaxants such as Soma are more likely to cause adverse outcomes and therefore the patients request for the Soma is not indicated. Ballantyne and Mao reported that prolonged use of centrally-acting medications might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of medication therapy. Soma as requested by the patient would be contradictory to providing safe and effective healthcare. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Norco 10-12 per day, #240 pills every 20 days for medical treatment of his chronic pain.  Findings: The physician reviewer found that current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that chronic opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. It would therefore, be in the best interest of the patient to participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. All told, the medical necessity of the requested mediation dosage has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a water circulating cold pad with pump for treatment of her medical condition.  Findings:  Two physician reviewers found that a water circulating cold pad with pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of high quality evidence that demonstrates that the use of active cooling devices results in better outcomes over the use of topical ice pack application. According to Hubbard and Denegar Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury. All told, a water circulating cold pad with pump was not likely to be more beneficial for the treatment of the patients medical condition than the available standard therapy.  Final Result: Two reviewers determined that the equipment 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:  All three reviewers are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by researchers, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: Three 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment program services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based on the physical and clinical assessments, a reasonable treatment plan was developed.  There was no subsequent documentation indicative of a change in status that would necessitate more intensive services.  Further, the medical records from the residential facility lacked critical documents useful in the level of care determination process.  Additionally, the patient had a safe residence and was motivated for care.  Despite the contemporaneous diagnoses of depression anxiety, the patient had no safety concerns.  She had not engaged in chemical dependency aftercare following previous residential admission.  There was no evidence to suggest that a less restrictive treatment setting would have been insufficient at the time.  Thus, residential treatment program services were not medically indicated 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 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 Mavyret for 100/40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to the recent 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 limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100/40 mg tablets for eight weeks to treat hepatitis C is supported as medically necessary. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee requested authorization and coverage of endoluminal radiofrequency ablation. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees varicose veins. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for referral to a fertility specialist. Findings:  The physician reviewer found that the enrollee has a medical history of hyperlipidemia and obesity and presented to an OB/GYN for a pre-conception consult. A prior pregnancy resulted in miscarriage. She is currently single and interested in conceiving this year with donor sperm. Risks of pregnancy, likelihood of conception at advanced maternal age (AMA) and management of her co-morbidities were discussed. The OB/GYN referred the enrollee to a perinatologist for a pre-conception consult. The OB/GYN also referred the enrollee to a reproductive endocrinologist for bloodwork, evaluation, and discussion of intrauterine insemination (IUI). The enrollee presented for a consult with an OB/GYN specializing in maternal and fetal medicine. Risks of co-morbidities during pregnancy and fetal chromosomal abnormalities were discussed. The specialist concluded there are no absolute contraindications to pregnancy and placed a referral to a reproductive endocrinologist. The reviewer determined that, according to the medical literature, the services of a fertility specialist are warranted. Due to her  advanced age, she will be a high risk pregnancy and more immediate evaluation and treatment by a fertility specialist is medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in reproductive endocrinology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for advanced wound therapy with placental tissue matrix allograft. Findings:  The physician reviewer found that there is a lack of data in current medical literature supporting the use of placental allografts over standard wound therapies, including periodic debridement, offloading, off weight bearing, contact casting, and possible skin grafting. Given the lack of peer-reviewed published studies available, it is not possible to evaluate the benefits or draw conclusions regarding the efficacy of the requested service. Therefore, advanced wound therapy with placental tissue matrix allograft is not likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested advanced wound therapy with placental tissue matrix allograft is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers 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 1 is a D.P.M., board certified in podiatry and is actively practicing. Physician reviewer 2 is a D.P.M., board certified in podiatric surgery and is actively practicing. Physician reviewer 3 is a D.P.M., board certified in podiatric surgery and is 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical air transportation for treatment of an emergency medical condition. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The medical air transportation and post-stabilization care provided were necessary for treatment of an emergency medical condition. A brainstem stroke in a young patient is one of the most critical neurological emergencies and often suggests a vertebral dissection. Brainstem strokes require extremely close monitoring, quick intervention if they progress, and an advanced level of diagnostic and management care. In this case, the patient necessitated angiography while at the tertiary center in order for further determine the extent of his vascular disease and initiate proper therapeutic management. The angiography demonstrated evidence of a vertebral dissection and guided care. Rapid transfer to a tertiary center given the documented facts of this case was necessary. The absence of this care and appropriate transfer would have placed the patient at unnecessary risk for severe disability and potentially death. Moreover, the post-stabilization care received was necessary for treatment of an emergency medical condition. This was an emergent situation.  The patient had a stroke with significant brainstem findings. Post-stabilization care included close clinical monitoring and an angiogram both are necessary for patients with tenuous brainstem strokes. The absence of this care would have placed the patient at risk of death or severe disability. Therefore, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue. Final Result: The reviewers 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: Physician reviewer number one is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male has requested for continued stay at an out-of-network burn center for treatment of his lower extremity burns.  Findings:  The physician reviewer found that there is no documentation in this case to suggest that this patient was not stable for transfer (e.g., documentation of cardiac or pulmonary instability) and the documentation does suggest that the patient was not transferred because he refused to be transferred, and wished to stay in the facility.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested psychiatric partial hospitalization treatment for his major depressive disorder.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that a step-down in the patients level of care was contraindicated. On that day, significant changes were made to his medications. Both of the patients antidepressants were discontinued and replaced by a third, and his dosage of Klonopin was also adjusted. Thus, additional time was needed to monitor the patients response to the changes in his medication regimen. Additionally, upon discharge the patient was going to return to significant environmental stressors, including personal medical issues and family conflict. The treating providers appropriately judged that the patient was not ready for discharge and the services at issue were clinically indicated.