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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right cervical medial branch radiofrequency ablation (RFA) procedure at C3-4, C4-5 and C5-6. Findings:  The physician reviewer found that the efficacy of cervical RFA found that, The evidence shows a majority of patients were pain free at six months and over a third were pain free at one year. Manchikanti and colleagues concluded that, The evidence for long-term improvement with cervical radiofrequency neurotomy is Level II with moderate strength of recommendation, when performed after the diagnosis of cervical facet joint pain with controlled comparative local anesthetic blocks utilizing 80% pain relief criterion standard. In addition, the authors reported that repeat RFA procedures can provide the same benefit as with the initial procedure. In this case, the patient has chronic neck pain which is mechanical in nature. He has undergone multiple rounds of cervical facet joint injections, which were diagnostic. These diagnostic procedures were followed with cervical RFA procedures, which the provider reported have provided improvements in the patients pain, function, and quality of life. Based on the medical records and current medical literature, the requested right cervical medial branch RFA procedure at C3-4, C4-5 and C5-6 is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 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

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for substance use residential treatment center (RTC) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does support the medical necessity of the services at issue. In this case, the patients alcohol use contributed to health, legal, occupational and interpersonal issues. The patient drank to self-medicate feelings of anxiety and overly harsh self-criticality. The patients overconsumption of alcohol placed self and possibly others at risk, as evidenced by the patients high-risk behaviors. Although poorly documented, there was concern for anxiety and depression. Anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes. Notwithstanding, the patient had failed treatment in a less restrictive setting and was referred to a residential treatment facility.  It is common practice to advance the level of care when less restrictive settings are inadequate. In sum, the services and setting were safe, appropriate and consistent with good practice in the United States, while the duration of treatment aligned with community standards. Additionally, the services provided at the time were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Considering the clinical presentation and perusal of the relevant peer-reviewed literature, substance use residential treatment center (RTC) services were medically necessary for the treatment of 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 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 73-year-old female has requested coverage for surgical intervention and related services provided.    Findings:  The physician reviewer found that the patient was treated in Mexico for pelvic organ prolapse. She underwent extensive work-up including colonoscopy, barium enema, colonic transit study, pelvic and abdominal ultrasound, and blood work. She also underwent surgery for what is described as an emergent situation due to rectal bleeding. The patient underwent cystocele repair, rectopexy, and lifting of the pelvic floor. She remained in the hospital for approximately three days. There is no documentation of any other preceding treatment or evaluation in the United States to confirm reports that the patients physicians could not determine the etiology of her problem.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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.It is reasonable to conclude that a prudent layperson would have sought immediate evaluation for rectal bleeding. However, other than the colonoscopy, the remaining work-up would be considered elective and unrelated to the bleeding. Furthermore, the subsequent diagnoses were most likely not a cause of any sort of significant rectal bleeding and the surgical procedures performed were elective and not related to any emergent procedure. As such, while a prudent layperson would have sought immediate medical attention for rectal bleeding, once the colonoscopy was performed, a prudent layperson in this situation would not have reasonably believed immediate surgical intervention and related workup was required.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Harvoni has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. In this case, the patient presents with chronic HCV genotype 1a and is treatment-naive. Therefore, Harvoni is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old woman who has a history of vitiligo involving at least her hand and knees. The submitted information indicates treatment with Estrostep, Protopic, Westcort, and Psorcon has been unsuccessful. The patient has been using Elidel cream with improvement of the knee lesions and some improvement of the hand lesions. She has requested authorization for continued use of Elidel. The Health Plan has denied the request on the basis that the requested medication is not medically necessary for treatment of the patients medical condition.Vitiligo can be a disfiguring skin condition. Success with any treatment modality is occasional. Review of the submitted documentation appears to indicate that Elidel has resulted in improvement in some of the patients skin lesions. As such, it is medically reasonable and appropriate to continue treatment with Elidel. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of the left and right perforator veins. The documentation reviewed does not provide adequate evidence that the requested radiofrequency ablation of the left and right perforator veins is likely to be more beneficial for this patient than standard treatment options. Specifically, it is not possible to attribute the patients pain to his residual superficial venous reflux without assessment of arterial perfusion. Routine assessment and treatment include assurance of satisfactory arterial perfusion to the lower extremities bilaterally prior to proceeding with further endovenous treatments. This is especially important for this patient since compression stockings and at least four endovenous procedures have failed to provide satisfactory pain relief. Therefore, the requested radiofrequency ablation of the left and right perforator veins is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested radiofrequency ablation of the left and right perforator veins 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 reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in general vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested topical compound pain medication for the treatment of her atypical facial pain. Findings:  The physician reviewer found that facial pain is difficult to treat effectively for many patients. Often numerous medications and treatments have been used with no relief. The more resistant the pain, the more treatments that are tried, and frequently the new treatments fail as well. The current use of topical medications appears promising for pain relief, but has not been proven by evidence-based studies to be any more effective than placebo. One study attempted to find any traces of the chemical in the blood, and was not able to find even trace amounts. At this time, the use of topical pain medications is not the standard of care. There is not enough medical literature that supports the efficacy of topical agents such as Ketamine HCl for the treatment of pain to warrant their use in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. Findings: There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Sheu and colleagues concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best evidence review concluded that long-term comparative outcome data past [one] year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval (Bauer, et al). One peer-reviewed journal published a letter stating that there have been reports of endoscopically confirmed LINX erosion through the esophagus in the U.S. Food and Drug Administration (FDA) Adverse Events database (Bielefeldt). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, LINX is not likely to be of greater benefit than the available standard options for the treatment of this patients medical condition.Final Result: Two of the three reviewers have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

The parent of a 12-year-old female enrollee has residential treatment services for treatment of the enrollees anorexia nervosa, restricting type. Findings:  The physician reviewer found that the submitted evidence demonstrates that this 12-year-old patient has a history of anorexia nervosa restrictive type. She was found to be below her 85% ideal body weight.  This patient's BMI increased yet her percentage of ideal body weight remains below 85. She continues to have difficulty with restriction of her food intake and shows manipulation of her eating process. The patient continues to make progress but has not shown a clear ability to function without consequences outside of the residential treatment facility. Thus, the request for continued residential treatment is reasonable and medically necessary, as the patient continues to show severe restrictive behaviors and manipulating behaviors that require the intensity of 24-hour supervised care.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested residential treatment for treatment of his major depression, anxiety disorder, panic disorder, attention deficit/hyperactivity disorder, executive functioning disorder, learning disorder, and persistent complex bereavement-related disorder.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In a letter the outpatient psychiatrist summarized the patients care.  However, there is an absence of medical records which are needed to justify the medical necessity of the services at issue.  First, there are no treatment records detailing care prior to the residential placement.  Without clinical documentation, the status of the patient and any barriers to progress cannot be determined while the impression and recommendations of the provider remains unknown.  Further, the absence of an initial psychiatric assessment at the residential treatment point of entry and serial clinical assessments renders it impossible to determine the necessity of the placement at the time and the appropriate length of stay at the level of care.  Thus, based on the clinical documentation provided, residential treatment provided during the said timeframe were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested a consultation for weight loss surgery (laparoscopic gastric banding) for treatment of her obesity and high blood pressure. Findings:  The physician reviewer found that this patient meets standard definition for clinically severe/morbid obesity, including the National Institutes of Healths consensus guideline criteria with a BMI of at least 35 and hypertension which is poorly controlled with medication. This patient appears to have failed prior dietary efforts and there is no documentation of any treatable metabolic causes of obesity with a normal TSH. This patient meets medical necessity criteria for referral for a bariatric consultation. The patient should be authorized to proceed with a lap band evaluation to determine if she is an appropriate surgical candidate.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested for artificial disc replacement surgery for treatment of  her degenerative disc disease. Findings:  Two physician reviewers found that artificial disc replacement is a novel surgical option for the management of discogenic lower back pain. To date, there is no long-term data supporting the benefits of this procedure over more conventional surgical interventions such as fusion. It has not become standard of care for management of degenerative disc-related pain. Long-term safety and efficacy studies are lacking in the peer-reviewed literature along with head-to-head comparison between total disc replacement and interbody fusion surgery.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male has requested occupational therapy, at a frequency of one session per week for treatment of his sensory processing disorder.  Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman; and Polatajko and Cantin). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children, when sensory processing concerns exist.  A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. This patient has identified fine motor delays and sensory processing issues. Given the history of colpocephaly in addition to his noted delays in fine motor and sensory processing skills, occupational therapy at a frequency of one session per week is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that the proposed treatment with Sovaldi is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus (HCV) genotype 2. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed treatment with Sovaldi has been approved by the FDA based upon a large trial involving genotype 2 and 3 patients.   This regimen has also been endorsed by the AASLD/IDSA in their guidelines for the treatment of HCV patients. The initial phase three studies (FISSION, FUSION and POSITRON) demonstrated that the Sovaldi regimen was well-tolerated, safe and efficacious. As such, Sovaldi is medically necessary for treatment of the 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for 50 hours per month of applied behavioral analysis (ABA) therapy, five hours per month of supervision and one hour per month of individual parent training services provided for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the despite more than six years of ABA therapy, the patient continues to have language deficits and aggressive outbursts. The request for 50 hours per month of ABA therapy is not likely to improve his medical condition. In this clinical setting, the Health Plans authorization of one hour per month of parent training, two hours per month of supervision, and 20 hours per month of one-on-one ABA is medically appropriate for this patient.  Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in child 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.