Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for actigraphy testing performed for evaluation of the enrollee, who reported a history of excessive daytime sleepiness. Findings: The 3 physician reviewers found that Circadian rhythm sleep disorders, such as delayed sleep phase syndrome, have traditionally been diagnosed on the basis of patient histories. Traditionally, sleep logs or sleep diaries have been utilized in clinical practice to record a patients sleep wake schedule.  In the past decade, actigraphy was developed as a technology, and it gained use in research studies and in some aspects of clinical practice. Colleagues published a study in which actigraphy and sleep logs were both utilized to evaluate patients with insomnia. The authors noted sleep diary parameters discriminated individuals with insomnia from good sleepers more accurately than actigraphy. Other studies have not shown that actigraphy is superior to patient reported/recorded values. In the clinical documentation provided for review, the patients self-reported sleep schedule was corroborated by the findings of his actigraphy study.  At this time, the literature has not established that actigraphy is more effective in establishing a diagnosis of a circadian rhythm sleep disorder than the use of sleep logs/diaries in adult patients who are able to maintain such record. Therefore, actigraphy testing performed was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in neurology with sub-specialty certification in sleep 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested inpatient mental health services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patient remained at a severely depressed level of functioning with paranoia, looseness of associations, and dementia. Based on the records provided, she met continuing care criteria for inpatient level of care, as she had developed new symptoms of paranoia and dementia that were as severe as her admission symptoms of depression and eating disorder. The providers noted a treatment plan to focus on stabilizing the patient for discharge. Given this patients depressed level of functioning, the patient remained at risk for relapse and return to inpatient care. All told, the inpatient psychiatric services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested reimbursement and prospective authorization and coverage for weekly exposure therapy. 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. Prior to the disputed timeframe, the patient was engaged in outpatient therapy and reported infrequent panic attacks. The records do not document that the patient had suicidal or homicidal ideation. She was not displaying aggression or self-injurious behaviors. The patient was not experiencing signs of psychosis. She was able to manage her activities of daily living in a developmentally appropriate manner. During the dates of service in dispute, the patient was calm and cooperative, without suicidal or homicidal ideation. The records do not document that the patient was an immediate danger to self or others. The clinical notes do not document that the patient was immediately unable to care for herself. The patient did not display significant symptoms that warranted emergency treatment or evaluation according to Health and Safety Code section 1317.1. Therefore, weekly exposure therapy were not emergency psychiatric services as defined by the Health and Safety Code section 1317.1.With regards to weekly exposure therapy from, the records support the medical necessity of the services at issue. Exposure therapy is typically used for anxiety disorders. This patients therapy sessions have addressed psychoeducation. The sessions discussed thoughts associated with anxiety. Per the records, the sessions were cognitive behavioral therapy (CBT) focused as well as exposure focused. The medical literature suggests that exposure therapy is similar to the outcome with treatment with CBT. These two forms of psychotherapy are evidence-based treatments in this clinical setting. Therefore, weekly exposure therapy from was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not emergency services as defined by California law. The reviewer determined that the services at issue were and are medically necessary to treat the enrollees medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the 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 AASLD and IDSA guidelines recommend that non-cirrhotic treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for partial hospitalization program (PHP) services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.  Findings: The documentation submitted supports the medically necessity of the services at issue in this clinical setting. The patient has a longstanding history of eating disordered behavior.  Per the documentation provided, since discharge from the residential facility, the patient has re-engaged in eating disordered behavior by restricting meals. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history provided and documentation as outlined above, this patient meets CASII criteria for Level 4 intensive integrated services without 24 hour psychiatric monitoring. This level of care is higher than intensive outpatient services.  The patients clinical status, in addition to current medical literature, support treatment at a partial hospital program level of care. Accordingly, the requested partial hospitalization program 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 internal medicine with sub-specialty certification in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two 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.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms.  Thus, breast tomosynthesis was not likely to have been of greater benefit than other modalities.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 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: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested the medication Tarceva for treatment of his recurrent glioblastoma multiforme. Findings:  Two physician reviewers found that there is a lack of data demonstrating the efficacy of Tarceva for the treatment of this patients medical condition. The article by Sathornsumetee and colleagues was submitted with this appeal. In this non-randomized study, 57 patients (25 with glioblastoma) were treated with the combination of Avastin and Tarceva. The median progression-free survival was 18 weeks, and the median overall survival was 44 weeks.  The authors concluded that although the combination was well-tolerated, the clinical benefits were not improved compared to other Avastin salvage therapy.  All told, the superior efficacy of the medication Tarceva in this clinical scenario has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested outpatient mental health sessions at a frequency of four times per week for treatment of his mental health condition. Findings:  The physician reviewer found that no clinical information was submitted for review. There is no evidence in the documentation provided that the patient has received a full assessment according to American Psychiatric Association practice guidelines or received a DSM-IV-TR diagnosis consistent with current consensus and standard of psychiatric practice. Since no clinical information has been submitted, the presence of a psychiatric condition for which psychotherapy is indicated has not been established. Thus, the submitted documentation has not demonstrated the medical necessity of outpatient mental health sessions at a frequency of four times per week provided during the period at issue.  Additionally, the medical necessity of continued outpatient mental health sessions at a frequency of four times per week has not been demonstrated. All told, there is no clinical evidence demonstrating that psychotherapy of any frequency is medically indicated in this patients case.
Appeal type: Urgent Care
Decision: Upheld

A 29-year-old female enrollee has requested emergency services for the treatment of her urinary tract symptoms. Findings:  The physician reviewer found that this patients Health Plan provides emergency services when medically necessary. An emergency medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention to result in placing the members health in serious jeopardy. This patients symptoms had commenced gradually over three days. She reported pain with urination, but did not require pain control in the emergency department nor prescription pain medication. Since her symptoms were not acute in onset and her pain was not severe, this patients symptoms do not meet criteria for an emergency.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee who requested authorization and coverage of breast reduction surgery for treatment of gynecomastia.  The health plan denied the request, indicating that the requested surgery is not medically necessary for treatment of the enrollees medical condition.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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested extracorporeal shock wave therapy for the treatment of her plantar fasciitis. Findings:  Three physician reviewers found that extracorporeal shock wave therapy has been employed in the treatment of plantar fasciitis, but the results have not been clearly defined.  There have been many reports of good results, but there are also many papers indicating a lack of definite evidence of clinical efficacy. This therapy remains investigational, and the Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the upper extremity (CPT 73221) for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Wrist abnormalities are less commonly evaluated, but that is due to the lesser frequency of wrist abnormalities that are amenable for surgical cure. In this case, the MRI of the upper extremity was clinically indicated as it allowed the provider to define ligamentous or tendon abnormalities. As discussed in the medical literature, MR imaging is a powerful method for evaluating acute and chronic lesions of the stabilizing articular elements (volar plate and collateral ligaments) of the fingers and thumbs, particularly in the frequently affected proximal interphalangeal and metacarpophalangeal joints. Furthermore, the medical literature states Magnetic resonance imaging represents a relevant way to diagnostically assess the wrist with high-resolution, multiplanar imaging without employing ionizing radiation. It influences clinical and surgical diagnosis and management of wrist pathologies.  In conclusion, the MRI of the upper extremity (CPT 73221) was medically necessary as it provided the information necessary to make a surgical decision.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested continued physical therapy (PT) for treatment of her back and neck pain. Findings:  The physician reviewer found that based on available records, PT has not resulted in any objective progress since 12/28/06. The submitted physical therapy notes do not demonstrate significant functional improvement and treatment goals have not been met. Additional physical therapy is not likely to result in an improved clinical outcome.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old male enrollee has requested a LINX device surgically implanted around the esophagus for treatment of his gastroesophageal reflux disease, dysphonia and sore throat. Findings:  Two physician reviewers found that LINX is a minimally invasive anti-reflux procedure. The alternative in this setting is a fundoplication procedure. However, a systematic review of more than 6,318 abstracts, 53 cohorts and 10 controlled studies has shown that it remains unclear which patient characteristics influence post-operative success following fundoplication for GERD. (Ip, et al.) LINX has been shown to be as effective as fundoplication and is considered less invasive, with fewer side effects. LINX has the added advantage of being potentially reversible as opposed to permanent anatomic reconstruction which accompanies surgery. All told, the requested LINX procedure is the most minimally invasive option for this patient and has the best chance of a successful outcome. Accordingly, the LINX procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Overturned

A male enrollee requested urgent care services on an emergent or urgent basis.  Findings:  The physician reviewer found that the patient attempted appropriate home care for upper respiratory infection which failed and his symptoms worsened with fever, facial pain, purulent nasal drainage, and a persistent cough with brown sputum and mild dyspnea. A prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. Further, it has been established that criteria for urgently needed services were met. In sum, based on the patients clinical presentation he did meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nivolumab (Opdivo) 240 mg intravenous (IV) every two weeks and bevacizumab (Avastin) 2.5 mg/kg IV every two weeks. The U.S. Food and Drug Administration (FDA) has not approved the combination of Opdivo, Avastin, trametinib, and lapatinib for the treatment of metastatic cholangiocarcinoma. Moreover, there is a lack of medical literature or guidelines to support the safety and effectiveness of this therapeutic regimen. Further, Avastin and Opdivo are not within the standard of care for the treatment of metastatic cholangiocarcinoma as noted by the National Comprehensive Cancer Network (NCCN) guidelines. The records indicate that this patient has been treated with some of these medications with positive response. However, given the limited data demonstrating the efficacy of the requested medications in this clinical setting, the continued use of Avastin and Opdivo is not supported. For these reasons, the requested Opdivo 240 mg IV every two weeks and Avastin 2.5 mg/kg IV every two weeks are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 oncology 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.