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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling (gene test). Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. All told, the gene expression profiling (gene test) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was 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 dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for incontinence supplies. The Health Plan has denied this request indicating that the requested supplies are not medically necessary for treatment of the enrollees incontinence. Findings: The documentation provided does not support the medical necessity of the requested supplies in this clinical setting. There is no documentation to support fecal or functional incontinence. Functional incontinence is when a patient does not have an anatomical or neurological problem with the bladder but is unable to toilet themselves in a timely fashion due to an underlying medical illness; conditions like dementia, mental illness, or decreased mobility.  In this case, the provider notations did not provide support for a diagnosis of functional incontinence. Instead, the records appear to support the diagnosis of urinary stress incontinence, which is usually caused by weak pelvic floor. The requested supplies are generally prescribed for a diagnosis of functional incontinence. Initial treatment for urinary incontinence includes lifestyle changes including weight loss, dietary changes, treatment of constipation or smoking cessation.  There is a lack of documentation to support that this patient has failed treatment with more conservative measures. The medical literature support pelvic floor exercises as an effective treatment modality for urinary stress incontinence. Although many women use pads and protective garments these supplies do not address the underlying cause of urinary leakage. As such, the requested incontinence supplies are not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested supplies 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 internal 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: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested viscosupplementation injections for treatment of his degenerative joint disease of the knee. Findings:  Three physician reviewers found that the issue in this case is whether the requested repeated courses of hyaluronate injections, are likely to be more beneficial to the patient than available standard therapies. In the peer reviewed medical literature, the value of viscosupplementation with hyaluronates has been generally accepted as a treatment for osteoarthritis of the knee (Brzusek and Petron). It is most suitable in patients with mild to moderate involvement and is much less effective in patients with more severe levels of disease (Jorgensen, et al). In addition, the efficacy of repeated courses of treatment is not well established (Espallargues and Pons). Some reports, as noted by Waddell and Bricker, have been favorable, but the available evidence is not sufficient to reach firm conclusions. Currently, clinical trials are in progress, but the results are not yet available. Therefore, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 27-year-old male with a long history of behavioral health problems. He has a history of prior hospitalizations. Prior pharmacologic treatment included mood stabilizers, neuroleptics, and antidepressants. In December 2004, the patient discontinued his medications and began using cannibus and abusing alcohol. In February 2005, he was admitted to a prison psychiatric unit after violating a restraining order.  In April 2005, the patient was transferred from the prison psychiatric unit to an acute inpatient psychiatric treatment program. The Health Plan has denied coverage for the patients acute inpatient admission on the basis it was not medically necessary for treatment of the patients condition.It is apparent from the enclosed documentation that this patient is chronically and persistently mentally ill. He has a long history of delusions and hallucinations. His psychotic symptoms are rather severe. No doubt that his illness has been exacerbated at times by the use of multiple substances. However, he also demonstrated severe symptoms while hospitalized on a locked unit. This patient as evidenced by the documentation provided responds best in the most structured, highest level of care. As such, the patients admission to a residential level of care was medically indicated for treatment of his chronic mental illness. Based upon the information set forth above, I have determined that the services at issue were medically necessary for treatment of the patients condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 65-year-old male enrollee has requested reimbursement for skilled nursing home care services provided for five (5) days at the end of September 2018. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees osteomyelitis.At issue in this case is whether the skilled nursing home care services at issue, provided from for five (5) days at the end of September 2018, were medically necessary for treatment of the enrollees medical condition.Per Hakkarainen and colleagues the surgical population is aging, and greater numbers of surgical patients are being discharged to skilled nursing facilities. Post-acute care is a poorly understood but very important aspect of our healthcare system. The role of the care setting and care delivery in contributing to outcomes has not been well studied, and no strong conclusions can be made.  The progress note from the patients podiatrist dated mid-September 2018 advises extremely good healing of the right forefoot with a small Wagner grade 1 superficial ulceration. It is noted that the left toe amputation is completely healed. During this visit the podiatrist recommended continued skilled nursing facility stay for dressing changes and bed rest. It is further noted that the dressing orders were changed to a simple normal saline pat dry, apply medical honey with dry dressing daily. It was recommended that the patient be discharged to home. Taking into account the physical exam and recommendations from both the podiatrist and the nursing staff, the patient could have been transitioned home in the end of September of 2018. Therefore, skilled nursing home care services were not medically necessary for five (5) days at the end of September 2018.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 podiatry 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 patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services for treatment of the enrollees schizophrenia.  Findings:  The physician reviewer found that based on the available documentation, the services provided could not have reasonably been delivered effectively in a less restrictive setting. The records document that this patient has a prominent formal thought disorder. He is being treated with two potent antipsychotics, lurasidone and clozapine, as well as a mood stabilizer, divalproex. Although the psychiatry notes from report some progress, the patient continues to demonstrate disorganized thinking, episodic irritability and emotional reactivity leading to self-defeating behaviors. In sum, the patient has not consolidated the treatment gains necessary to succeed in a less restrictive setting. The setting and services, which include evidence based interventions such as dialectical behavioral therapy (DBT), assertive community treatment, mindfulness, cognitive rehabilitation, art therapy, psychoeducation, individual therapy and pharmacotherapy, remain appropriate and consistent with good medical practice. Moreover, these services are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, the IOP services were and are medically necessary for treatment of the patients behavioral condition. 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 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 enrollee requested coverage for Humira. The patient is a 58-year-old male with psoriasis and psoriatic arthritis. The patient was seen by his rheumatologist in January 2020 for erosive disease in the feet with left 1st metatarsophalangeal joint ankylosis that was seen on x-ray. He also has signs of degenerative joint disease on x-ray. On 06/15/20, he reported joint pain, joint swelling, and more than 90 minutes morning stiffness. The treating rheumatologist has recommended Humira. The 2018 American College of Rheumatology / National Psoriasis Foundation Guidelines for the Treatment of Psoriatic Arthritis are a prominent set of guidelines for the treatment of rheumatoid arthritis. They report erosive disease is part of the definition of severe psoriatic arthritis. Anti-tumor necrosis factor therapy such as Humira is preferred over oral agents and other types of biologics as initial treatment for severe psoriatic arthritis. The use of Humira in this case is supported by the documentation and professional guidelines.Final Result: The reviewer determined that the Humira 40mg/ml Pen is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested ambulance services on an emergent or urgent basis for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought ambulance transport on the date in question. In this case, the patients parent called 911 due to nausea, vomiting and the patient becoming unresponsive. Most likely the patient had a vasovagal (neurocardiogenic) syncope and recovered spontaneously prior to EMS arrival. In addition, the patient had already been treated for recent infectious illness and he developed the vomiting which had persisted for a protracted period of time. In this clinical scenario, it is an appropriate parental concern for possible dehydration, electrolyte imbalances, and other serious conditions which may be manifested by an alteration in the level of consciousness. Thus, the patients symptoms were of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did meet prudent layperson criteria for ambulance transport.  Result:  The reviewer found that the patients symptoms met prudent layperson criteria for ambulance transport services. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in emergency 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 thighplasty and panniculectomy. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Medical literature noted that the criteria for treatment by panniculectomy are that the panniculus hangs below the level of the pubis and the medical records document that the panniculus causes chronic intertrigo that consistently recurs over three months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy over a period of three months. This patients panniculus does not appear to hang below the level of the pubis. The patient complains of skin breakdown underneath her abdominal pannus, but there is no report of appropriate medical treatment of skin breakdown or of failure of appropriate medical treatment of skin breakdown. The patient does not have a functional problem with skin breakdown demonstrated to be resistant to appropriate medical treatment for more than three months. Based on the medical information received for review and evidence-based literature, the requested panniculectomy is not medically necessary for treatment of this patient. Moreover, the patients abdominal pannus following weight loss is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The abdominal pannus is not an abnormal structure of the body. The patients pannus is a normal structural change that is an accommodative response to loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The requested panniculectomy is not being requested to address a functional deficit and would not make a more than minimal improvement in the patients appearance. Accordingly, the requested panniculectomy is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in plastic 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: Overturned

Nature of Statutory Criteria/Case Summary: A transgender female enrollee has requested reimbursement for facial feminization surgeries (frontal orbital bone contour; brow lift with endotine; rhinoplasty; jaw/chin contour). Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria (including surgery on some occasions) aims to minimize dysphoria and help patients attain their sought-after gender role. Researchers find that facial feminization procedures are not cosmetic, but rather serve a primarily reconstructive purpose in transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Researchers note that the medical procedures attendant to sex reassignment are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Researchers find that gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. In sum, based upon the submitted clinical documentation establishing the severity of the patients gender dysphoria related to her facial features, as well as the available literature demonstrating the medical necessity of gender reassignment procedures including facial feminization for the treatment of gender dysphoria, the services at issue were medically necessary and appropriate for treatment of this patients condition.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 with expertise in treatment of gender dyphoria 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 deep brain stimulation (DBS). Standard therapies for medically refractory epilepsy include anti-epileptic medications, surgical resection, vagal nerve stimulation, responsive neurostimulation, and DBS. The records provided for review document that this patient is already on four anti-epileptic medications and the addition of another or alternative medications has an extremely low likelihood of providing substantial improvement. The patient is not a good candidate for additional invasive monitoring given the complications related to most recent procedure. This rules the patient out as a candidate for surgical resection. DBS is U.S. Food and Drug Administration (FDA) approved for use in this clinical setting. This patient has endured multiple craniotomies in an attempt at seizure focus localization and resection, all of which have failed. Given this support, the requested DBS is 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 DBS is likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be 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 neurological 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: Overturned

A male enrollee requested substance use partial hospitalization program (PHP) services for medical treatment of his alcohol dependency.   Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines suggest that PHP should be considered for patients who require intensive care but have a reasonable probability of refraining from illicit use of substances outside a restricted setting. The records indicate that if the patient was discharged early, he would have been at high risk for relapse and he continued to require safe and stable living environments in order to develop  recovery skills. Consistent with these findings, the PHP services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 68-year-old male enrollee has requested community based adult services (CBAS) for treatment of his type II diabetes and hypertension.  Findings:  The physician reviewer found that the Institute of Medicine Committee on the Quality of Long-Term Care Services indicates that many patients currently receive some type of long-term care (LTC) in their own homes or in residential care settings other than nursing facilities. CBAS offers services to eligible older adults and adults with disabilities to restore or maintain their optimal capacity for self-care. This patient was assessed as being within normal limits neurologically. In addition, he is independent in all ADLs except for assistance with meal preparation and accessing resources. For these reasons, he does not meet the criteria for participation in a CBAS program. CBAS is not medically necessary for this patient.