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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services.  Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder. Overall, the patient demonstrated significant symptoms that warranted emergency treatment according to Health and Safety Code section 1317.1. Applying the LOCUS criteria, this patient presented with serious risk of harm (score 4), due to compromised ability to care for herself. The patient demonstrated moderate functional impairment (score 3) as evidenced by her inability to work, identify support, and function in her marital role. The patient had significant comorbidity (score 3) as evidenced by spiral fracture of her right arm, recent alcohol use, and contentious home situation. The patients recovery environment was extremely stressful (score 5) considering that her husband kicked her out of the house. Her recovery environment provided limited support (score 3). The provider noted that no one accompanied the patient to the emergency department. The patients brother provided transport to her stepdown to transitional living center. The patient has shown limited response to treatment (score 3) as the records noted that she was discharged just four days prior and she decompensated in that short timeframe. The patients caretaker has been obstructive (score 3). The caretaker was unable to work constructively with the patients providers. The patient participated in treatment and was compliant with medications in the hospital. She was ultimately agreeable to be discharged to a transitional living center. This gives the patient a composite score of 24, which is consistent with medically managed residence based services, such as inpatient psychiatric hospitalization. Therefore, the emergency medical services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were emergency services as defined by California law and 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 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

A 59-year-old female enrollee has requested capsule endoscopy for evaluation of her iron deficiency anemia. Findings:  Two physician reviewers found that the submitted documentation does not support the requested capsule endoscopy in this patients case.  The medical records note that prior capsule endoscopy revealed an irregular appearing and thickened fold in the distal duodenum.  An enteroscopy is the gold standard method for further evaluation in this clinical setting.  The records do not demonstrate the utility of repeating the capsule endoscopy.  In sum, the requested capsule endoscopy is not likely to be superior over other methods of evaluating this patient.
Appeal type: Urgent Care
Decision: Upheld

A 38-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that this patient presented to the emergency department with complaints of left ear pain and hearing loss that persisted for 2-3 days. On evaluation, the patients vital signs were normal, she was not having a nosebleed when seen, and the physical examination revealed cerumen impaction as the cause of the pain and hearing loss. The cerumen was removed and the patient was discharged with a diagnosis of cerumen disimpaction. This case involves the issue of whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. An emergency medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient had symptoms that were persistent for more than two days and were not associated with severe pain or fever. Further, her nose was not bleeding at the time she sought emergency care. Since the patients vital signs were normal and her pain reportedly was not severe, a prudent layperson in these circumstances would not reasonably believe that the absence of immediate medical attention would cause serious impairment to her health or bodily function.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for sensory nerve response and lower extremity monitoring for legs. The records provided for review document that this patient presented with a significant deformity from congenital scoliosis. The surgery involved resection of vertebrae including close work to the spinal cord at the L1 level. Neural monitoring is appropriate when the anticipated surgical intervention is performed close to the spinal cord. Corrective spinal deformity surgery is a generally accepted indication for intraoperative neural monitoring to prevent reversible neurologic injury from realignment of the spine. The current evidence supports the use of neural monitoring in this patients clinical setting. Therefore, the sensory nerve response and lower extremity monitoring for legs were medically necessary for this patient.  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 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: An enrollee has requested authorization and coverage for an electric wheelchair. The submitted documentation does not support that the requested electric wheelchair is medically necessary. A study finds in the setting of neurologically-based mobility impairments, more active means of mobility are generally preferable to less active means of mobility for the purposes of general health promotion.In this case, the submitted records indicate that the patient has cervical spinal stenosis with some motor impairments in his right upper and right lower limb. He also has chronic pain and has been on opioids chronically. As regards the patients function, the records do not provide either a sufficiently detailed functional history or detailed examination to establish that the patients impairments are significant enough to preclude the use of a cane, walker or manual wheelchair to accomplish the patient's mobility-related activities of daily living. The records indicate that the patient had undergone physical therapy for gait training and that he has been ambulating short distances with a cane outside of the therapy setting. Accordingly, an electric wheelchair is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 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

A male enrollee requested Norco for medical treatment of his chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  The physician reviewer found that the records lack documentation that the patient has cancer or a condition that would support the use of Norco. The peer-reviewed literature indicated that opiates are not appropriate for the treatment of nonmalignant pain and not appropriate for the treatment of CIDP. Given the documentation, the requested Norco is not medically necessary for the treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for EsophyX Transoral Incisionless Fundoplication (TIF). Findings:  Three physician reviewers found that appropriate patient selection is crucial before anti-reflux procedures. The treating provider has recommended a TIF procedure. The technique has shown merit and durable response in selected GERD patients. However, this patient cannot be considered medically refractory, since she has opted for herbal supplementation in lieu of proton pump inhibitor therapy. Available records do not support contraindication to proton pump use. The records do not document that the patient has recently maximized available medical management. Per the literature, the patient is not likely benefit to a greater extent from TIF than from optimized acid suppression therapy, and there is significant risk for surgical complications of the proposed anti-reflux procedure. Accordingly, the requested services are not likely to be of greater benefit than other treatment options. 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 35-year-old female enrollee has requested Provigil for the treatment of her depression and anxiety with excessive sleepiness. Findings:  The physician reviewer found that there is very little supporting documentation of how Provigil has necessarily added to the patients welfare. From what little can be discerned, she still appears fatigued and irritable despite taking Paxil and Provigil. The dosage of Paxil was increased.  This does not speak very positively to the ostensible betterment of the patient by virtue of the noted combination. Hence, while there may be merit to it in general terms, there is a lack of support for the benefit of this medication for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential 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. The patient continues to show evidence of protracted withdrawal symptoms as evidenced by agitation, anxiety, sweating, tactile disturbances, and tremors. He is working with his providers on medical and psychosocial strategies to mitigate these symptoms. The patient has a history of intravenous drug use, which places him at heightened risk of contracting blood borne diseases. He is also at risk of contracting COVID-19 as he is homeless and given his known impulsive nature and history of overdose. The patient has sufficient mental status to permit participation. He is highly impulsive and his self-gratification and poor judgment make it difficult for him to control his substance use without 24-hour support. His functional deficits, such as planning to cut his wrists with a razor, and subsequent staff intervention further highlight his need for an RTC level of treatment. The patients perspectives impair his ability to make decisions regarding his care. His judgment has been impaired by his need for immediate gratification and inability to control his substance use outside of a structured setting. The patient continues to have protracted withdrawal symptoms that have required medication-assisted treatment and intensive psychosocial interventions. He has expressed that he would be unable to return to his home environment, where he has become aggressive, due to family stressors. The provider reported that the patient was found to have diverted medications and other paraphernalia while in the program and he continues to require intensive support and redirection. The patients recovery environment is too chaotic to support his goals of sobriety. He acknowledged that he is unable to return home and maintain sobriety. Given these findings, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction 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: Upheld

The patient has requested authorization and coverage for a Gallium 68 scan. Gallium 68 is used with positron emission tomography (PET) for localization of somatostatin receptor-positive neuroendocrine tumors for treatment planning at diagnosis or for suspected recurrence. The records provided for review document that this patient underwent treatment and was determined to have a good prognosis. Since that time, the patient has not demonstrated concerning signs or symptoms of recurrence. Moreover, Gallium 68 scans are not indicated for surveillance in this clinical setting. Therefore, the requested Gallium 68 scan 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 37-year-old female enrollee has requested for continuation of specific treatment by a specialist in vulvar disorders for treatment of her vulvodynia. Findings:  The physician reviewer found that there have been numerous proposed treatments for this condition, including vulvar care, topical, oral, and injectable medications, biofeedback, physical therapy, low-oxalate diet and calcium citrate supplementation and surgery. As per the ISSVD Vulvodynia Guideline, physical therapy also may improve intercourse frequency and may decrease pain with intercourse and gynecological examinations. Physical therapy treatment techniques include internal (vaginal and rectal) and external soft tissue mobilization and myofascial release, trigger-point pressure, visceral, urogenital, and joint manipulation, electrical stimulation, therapeutic exercises, active pelvic floor retraining, biofeedback, bladder and bowel retraining, instruction in dietary revisions, therapeutic ultrasound and home vaginal dilation. Different medications have been tried as treatments for vulvar pain. These include topical, oral, and intralesional medications, as well as pudendal nerve blocks.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested a myomectomy performed by a non-Plan provider for the treatment of her uterine fibroids. Findings:  The physician reviewer found that with the size of the patients uterus and the symptoms caused by her fibroids, it warrants surgical intervention. However, she was correctly counseled that a myomectomy would be a more risky procedure and that it may not provide definitive treatment. Studies have shown there is approximately a 15% chance that a second surgical procedure will be needed after conservative fibroid treatment and the likelihood increases when larger and more numerous fibroids are present. Moreover, the potential blood loss and need for blood transfusion are also greater with myomectomy versus hysterectomy. Nonetheless, myomectomy should still be considered a medically necessary treatment for this patient. When respectful persuasion fails to convince a patient that a hysterectomy would be the better procedure, myomectomy is in fact a relatively safe and effective option that should be available to those women wishing to retain their uterus.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Pylera capsules 1 box x 10 days. The patient has H. pylori infection found on endoscopy without a subsequent complete treatment. According to the American College of Gastroenterology (ACG) guidelines for the treatment of H. pylori, therapy is recommended in all positive patients, and Pylera is the first-line regimen for penicillin-allergic patients. Pylera has been demonstrated to be effective after failure of clarithromycin-containing triple therapy, and in patients who failed three prior triple therapies, including patients who are resistant to fluoroquinolones and metronidazole. The timing of drug administration is simpler than use of the generic bismuth quadruple therapy, resulting in a compliance rate above 95%. For these reasons, Pylera has been U.S. Food and Drug Administration (FDA) approved for the treatment of H. pylori, while generic alternatives have not been FDA approved. Therefore, the request for Pylera capsules 1 box x 10 days for the treatment of this patients H. pylori infection 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 subspecialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services provided for treatment of the enrollees substance abuse and eating disorder. Findings: The physician reviewer found that based upon the submitted documentation, the patient did not meet medical necessity criteria for RTC during the period at issue. Applying the level of care utilization system (LOCUS) criteria, the patient would have met the criteria for an intensive outpatient program (IOP) services from 10/1/16 through 10/18/16. The records indicate that the patient was at moderate risk of harm with no history of suicide attempts or suicidal ideation, but the patient reported that she had episodes of binge drinking to the point of intoxication (score of 3), moderate impairment in functional status due to ongoing problems with interpersonal relationships and social activities (score of 3), and significant psychiatric co-morbidity with bipolar disorder, anorexia nervosa, and alcohol use disorder (score of 3). The patients recovery environment is described as mildly stressful (score of 2) however, her family is documented to be supportive (score of 2). The patients treatment history includes moderate response to treatment with some sobriety typically under very structured settings (score of 3), and given the patients positive engagement and recovery (score of 2), the patient has a total score of 18, which is consistent with IOP services. Based on this criteria, the dates of service were not medically necessary. The patient could have been treated in a less restrictive environment in an IOP. The patient did not have any suicidal or homicidal ideation. The patient was motivated for treatment and she was sleeping well. The patient continued to require treatment, but this could have been done in a less restrictive environment in an IOP. Thus, the RTC services provided were not medically necessary for treatment of this patients behavioral health condition. 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.