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

Nature of Statutory Criteria/Case Summary: At issue in this case was whether the residential treatment center (RTC) services that were provided were medically necessary for the treatment of the patients behavioral health condition. The patient was admitted to the residential treatment center (RTC) services after completing detoxification at another facility. The diagnoses included alcohol use disorder and obsessive-compulsive disorder.The American Society of Addiction Medicine (ASAM) supports individualized treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. The ASAM criteria include: (1) acute intoxication and/or withdrawal potential, (2) biomedical conditions and complications; (3) emotional, behavioral, or cognitive conditions and complications; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. According to the ASAM 3.5, criteria were not met according to the patients presentation.Final Result: The reviewer determined that the requested services 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Octagam (IVIG).Findings: Two out of three physician reviewers found that Octagam (IVIG) is likely to be more beneficial for you than any available standard therapy.AIDP is a known complication following the administration of several vaccines as well as a complication following illness from several pathogens. CIDP is the chronic form of AIDP. AIDP and CIDP have both been documented in the literature after COVID-19 vaccinations as well as COVID-19 illness. Evidence for intravenous immune globulin (IVIG) in the setting of AIDP/CIDP, specifically secondary to COVID infection/vaccination related issues, is limited. AIDP and CIDP are well-known entities with established treatment recommendations. The management of these diseases involves the administration of IVIG. Additionally, IVIG is approved by the U.S. Food and Drug Administration in the setting of CIDP. There is no qualification on the pathogen or vaccine responsible to bring about the pathological immune response. Additionally, considering the novelty of COVID-19, it can be argued a standard therapy does not exist. In this case, neurophysiological testing is consistent with a severe sensory polyneuropathy in the lower extremities. Therefore, Octagam (IVIG) is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in neurology. All reviewers 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: Overturned

The parent of a three-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the role of speech therapy in autistic spectrum disorders is well published in the medical literature. Numerous citations recommend or demonstrate evidence for speech therapy for children with autism (Millar, 2006; Myers, 2007; and Volkmar, 1999). While there have been few studies offering a direct comparison of methods, experts believe that children with autism benefit from intensive, early intervention which focus on increasing the frequency, form, and function of communicative acts. Intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors (Paul, 2008). This young patient carries a diagnosis of PDD-NOS, which is an autism spectrum disorder (ASD). As concluded by Myers, and colleagues, the standard of care for young patients with ASD is speech, language, and communication therapy. Given this patients language delays as documented by both the in-Plan and out-of-Plan providers assessments, the patient is likely to show progress with speech therapy, which will improve his functional skills. Therefore, speech therapy is medically necessary for this patient. Regarding the requested occupational therapy services, each of the assessments documents the patients challenges with oral aversion. Further, the patient was evaluated a few months ago, and was found to have delays in self-care skills. Occupational therapy is a well accepted modality for patients with autism. Review of the relevant literature reveals adequate evidence supporting the use of occupational therapy to improve feeding issues and other activities of daily living. Given the patients multiple needs, the Health Plan should allow the patient to continue occupational therapy in order to address his oral aversion and other needs. Based on this patients documented deficits, occupational therapy is medically appropriate and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test, Guardant 360 for evaluation of her lung cancer. Findings:  Two physician reviewers found that multiplexed genotype testing, such as Guardant 360, allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially.  This is the most tissue-efficient approach, particularly when dealing with small tumor samples.  In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion.  Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Upheld

The patient is a 57-year-old male with severe xiphoid pain. Despite an extensive workup, the etiology of his pain remains unclear. The patient has requested an MRI of the chest and xiphoid process and CT guided trigger point injections. The Health Plan denied these requests based on a determination that the procedures are not medically necessary.An MRI is not likely to provide clarification as to the source of the patients pain. Additionally, CT guidance is not indicated or necessary for trigger point injections.  CT guidance is not the standard of care in performing trigger point injections. Since the requested procedures have little clinical usefulness in this setting, they are not medically justified. Therefore, I have determined the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested maxillary Lefort 1 reconstructive surgery, which includes mandibular osteotomy and genioplasty for the treatment of her dental facial deformity. Findings:  The physician reviewer found that the patient has a history of an inability to effectively masticate foods and given that she has an anterior open bite (lack of contact between maxillary and mandibular incisors and canines), the patient meets generally accepted criteria for orthognathic surgery. In fact, it appears that the patient meets the Health Plans own criteria for the procedure. In any event, the proposed surgery is medically warranted and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for major synovectomy of the right knee. Findings:  The physician reviewer found that available records document multiple diagnoses including plica syndrome, chondromalacia patella, and infrapatellar fat pad calcification. The providers notes referencing surgical intervention referred to a medial plica not identified on initial radiology review of the right knee magnetic resonance imaging (MRI) but was subsequently noted in an addendum to the radiology report. Plicae are small folds or shelves of synovial tissue that can rub or pop and contribute to pain and mechanical symptoms in the knee. Surgical treatment includes resection of the synovial prominence which corresponds to a synovectomy. In this case, the requested procedure is a major synovectomy, which would include two or more compartments. A major synovectomy may be appropriate for patients with synovial disease such as synovitis in the setting of inflammatory arthritis. However, evaluation and imaging of this patient does not indicate widespread synovitis throughout the right knee to support an indication for the requested major synovectomy . On review of the available documentation, the requested major right knee synovectomy of two or more compartments is not medically necessary and appropriate for this patient with knee pain attributed to a medial patellar plica. All told, the requested major synovectomy of the right knee is 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 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: Urgent Care
Decision: Upheld

A 58-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. 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. This patient had been suffering symptoms of phlegm in his throat and difficulty swallowing only when in the supine position. His symptoms had been present for weeks, and he had a known diagnosis of gastroesophageal reflux disease as well as an esophageal stricture. The patient was in no distress, and denied any pain or difficulty breathing. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a dosing regimen for the medication, Cialis. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Cialis (generic name tadalafil) for the treatment of erectile dysfunction (ED). A study notes that in a randomized, double-blind study of patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH), treatment satisfaction was greater with tadalafil over placebo. The authors further found that in patients with LUTS from BPH, tadalafil improved flow rates by 2.4 mL per second, compared with an improvement of around 2.2 mL per second with alpha blockers such as tamsulosin. The FDA dosage for the use of Cialis as needed is up to 10 mg once daily, with the possibility of increasing the dosage to 20 mg or decreasing the dosage to 5 mg, depending on efficacy and tolerability. For once daily use, the FDA recommends a dosage of 2.5 mg, which may be increased to 5 mg depending on efficacy and tolerability. In this case, the patient has diagnoses of BPH and ED. Given that current medical literature supports the use of and requested dosage of tadalafil for the treatment of these conditions, the requested medication is medically indicated. Therefore, a dosing regimen for the medication, Cialis, is medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Foundation One CDxTM comprehensive genomic profiling test (F1CDx). Molecular and biomarker testing has become an integral part the management of non-small cell lung cancer (NSCLC) as multiple targetable mutations help to inform on prognosis and direct therapy. Foundation One CDx comprehensive genomic profiling test can help identify these mutations. Guidelines by the National Comprehensive Cancer Network Guidelines (NCCN), American Society of Clinical Oncology (ASCO), and European Society for Medical Oncology (ESMO) for the management of NSCLC all recommend molecular and biomarker testing in this clinical setting. The U.S. Food and Drug Administration (FDA) lists NSCLC as an indication for F1CDx testing. Therefore, F1CDx was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the F1CDx at issue was 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 likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certifications in medical 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a dermatology consultation for treatment of her medical condition. Findings: The physician reviewer found that per the submitted records, the requested consultation with a dermatologist is medically necessary. Acne vulgaris is the most common dermatological disorder in adolescence and young adults. It is a chronic disease of the pilosebaceous follicle. Acne can cause disfigurement and permanent scarring. It can have an adverse effect on psychological development, resulting in profound emotional scarring, which may lead to social phobias, withdrawal from society and clinical depression. Per the records, the patients disease has recently relapsed requiring additional treatment. The patient requires a specialty consultation with a dermatologist to determine the appropriate course of treatment. As such, the requested consultation is medically necessary for treatment of her medical condition. Final Result: The reviewer determined that the requested consultation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturn.  Credentials/Qualifications: The reviewer is board certified in dermatology 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: Upheld

A 62-year-old female enrollee has requested emergency services for treatment of her skin tear laceration secondary to a cat scratch that occurred two days earlier. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. 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.At the time of her initial ER visit, this patient was advised that a wound check was required in two days due to the high risk of infection. As cats lick their paws, cat scratches can become infected with the same organisms as cat bites. While the patients condition warranted a follow-up medical evaluation, a reasonable person in this setting would have arranged for follow-up in a setting other than the ER. The follow-up visit did not need to be provided on an emergent basis. There were no concerning signs that would have cause a prudent layperson to seek emergency care for the follow-up visit. A prudent person in this setting would have believed that the necessary wound check could have been provided in a less urgent setting such as a physicians office (the following day) or urgent care center. Thus the patients symptoms did not meet prudent layperson criteria for emergency care and the denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical aortic aneurysm repair for treatment of her ascending thoracic aortic aneurysm.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. If surgery is done, it would require replacement of the ascending aorta, which is a procedure with definite risks, including bleeding, infection, stroke, myocardial infarction and multi-organ failure. Surgery for ascending aortic aneurysms are not undertaken unless the aneurysm measures over 5.0 cm, or there are other compelling reasons, such as rapid expansion, concomitant aortic dissection or Marfans features. None of these are present in this patients case. The mainstay of treatment in patients with 4.0 cm ascending aortic aneurysms is surveillance. All told, the requested surgical aortic aneurysm repair 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 thoracic and cardiac 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

A 62-year-old female enrollee has requested for bariatric surgery gastric bypass for treatment of her obesity and diabetes.  Findings:  The physician reviewer found that the medical necessity for the requested procedure has not been established by the records provided for review. Although this patient is obese, she is not morbidly obese as defined by standard guidelines. Applying the standard National Institutes of Health (NIH) consensus guidelines, this patient does not meet the criteria for bariatric surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested for continued physical therapy for treatment of his neck and back pain. Findings:  The physician reviewer found that the request for continued manual treatment is consistent with a maintenance program and not a restorative program at this point. As such, additional physical therapy sessions are not clinically indicated.