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

The parent of a five-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe the patient 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 experiencing a fever on and off for one week. Although she had developed a cough on the day she was evaluated, the patient was not experiencing chest pain or shortness of breath. The patient was febrile, but was in no distress. Her temperature responded to oral ibuprofen. This patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the parents circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a six to eight week program at a residential treatment center that specializes in posttraumatic stress disorder caused by childhood trauma. The progress notes indicate the patients main problems are due to family relationship issues as well as depression and anxiety. The patient denied a history of suicide attempts and does not have active substance use issues. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 2 due to a lack of current suicidal ideation and no history of suicide attempts. In terms of functional status, the records support a score of 3 due to significant inability to maintain family relationships with no indication of difficulties with activities of daily living. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to medical issues which are under control and no current substance use. In terms of level of stress of the recovery environment, the records support a score of 2 due to a stable living environment and no financial stressors. With regards to level of support of the recovery environment, the records support a score of 2 due to a positive relationship with her spouse. In terms of treatment and recovery history, the records support a score of 3 due to minimal treatment in the recent past and unclear response to recent medication treatment. With regards to engagement and recovery status, the records support a score of 3 due to cooperation in treatment and only limited insight into the need for treatment. Thus, the patient has a composite score of 17. This score correlates with high intensity community-based services. Therefore, a six to eight week program at a residential treatment center that specializes in posttraumatic stress disorder caused by childhood trauma 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for weekly home based occupational therapy and speech therapy for treatment of his brain cancer status post chemotherapy and radiation therapy. Findings:  The physician reviewer found that in the medical literature, researchers provided an analysis of home implemented speech therapy compared with school and clinics. The authors concluded that neither home nor outpatient services were found to be superior to the other. Other researchers compared home and school gait training programs and reported no significant outcome with either setting. Another study found no significance difference between home-based and center-based therapy after one year. This patients records indicate that the patient has had the benefit of speech and occupational therapy weekly sessions at home. However, over three months, the progress reports indicate only modest improvements. The additional records include weekly occupational and speech therapy reports. The occupational report states modest improvement in gross motor skills, balance and self-regulation. The speech therapy reports virtually no improvement over the time frame. Although the speech therapy report mentions in-home therapy, it does not specify a recommendation for in-home therapy. Neither does the occupational therapy report recommend in-home rather than outpatient treatment. Further, his parents concern regarding the overstimulation of the outpatient setting was not apparent when the patient was examined in the primary care providers office. Thus, there is no indication for in-home occupational and speech therapy and both therapies can be delivered in a clinic. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees stated condition of speech delay. Findings:  The physician reviewer found that the relevant scientific literature demonstrates that improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Speech therapy is indicated with any delay greater than 25% (Law, et al.). While speech therapy has been shown to be an effective modality for children with speech delay, based upon the documentation provided, this patient does not currently have any documented delays.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 37-year-old female with symptomatic internal derangement of both temporomandibular joints as confirmed by a December 2005 MRI. The patients symptoms include pain, locking, crepitation and diminished range of motion. Her attending surgeon indicates that the use of conservative measures such as NSAIDs, dental occlusional splints and soft diet have not been effective in reducing pain or improving function. Surgical intervention has been recommended. At issue is whether the proposed surgical procedures are medically necessary.The patient has symptomatic bilateral internal derangement of both temporomandibular joints with no resolution of her medical problem by non-surgical methods. Arthrocentesis of the joints with lavage and hydrodistention has been shown to be an effective treatment for this problem. As such, the requested procedures are medically indicated medical/surgical treatment in this case. The proposed treatment plan meets the standard of care within the medical community. Therefore, I have determined the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested for magnetic resonance (MR) neurography for treatment of her femoral nerve damage. Findings:  The physician reviewer found that Petchprapa and colleagues reported that [c]linically, femoral neuropathy is associated with decreased knee extension (quadriceps weakness) and decreased hip flexion (iliopsoas muscle weakness). An absent knee jerk and sensory deficits in the anterior and medial thigh and medial knee, leg, and foot are also noted. Femoral neuropathy may be clinically confused with lumbar plexopathy and L4 radiculopathy. Conservative treatment of femoral neuropathy should be attempted first, since the complications associated with surgical intervention can have serious consequences. Chhabra and Faridian-Aragh indicated that MR neurography is being increasingly used for peripheral nerve evaluation because it complements information gained from electrodiagnostic testing. However, in this patients case the documentation does not indicate that MR neurography would change her current treatment plan and the peer reviewed medical literature has not adequately demonstrated the efficacy of this procedure in changing patient treatment outcomes. Therefore, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested epidural steroid injections and radiofrequency ablation of facet joints for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  With regards to the requested epidural steroid injections, the records do not document a home exercise program, which is part of the recommendation of having active exercise with physical therapy.  The literature indicates that a home exercise program independent of an epidural may provide lasting results.  With regards to the requested radiofrequency ablation of facet joints, there should not be radicular pain at the targeted level.  If there is radicular pain, there needs to be documentation of an inadequate relief to epidural injections at that level.  In this case, the records document lower back pain relief from the facet injections.  However, details regarding the resulting relief of the radicular pain were not provided.  The records do not indicate whether the patient was able to avoid any analgesic during the diagnostic part of the injection for her leg pain as well.  This should have been documented in a pain diary for the diagnostic block to be viewed as meeting criteria for use in performing a radiofrequency ablation.  All told, the requested epidural steroid injections and radiofrequency ablation of facet joints are not medically indicated 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 anesthesiology with sub-specialty certification in pain 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium. Findings:  The physician reviewer found that Findings: Three out of three physician reviewers found that the authorization and coverage for computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium is likely to be more beneficial for the enrollee than any available standard therapy.Based on American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, an elevated computerized tomography (CT) calcium score would be considered a risk enhancing factor to determine the need for statin therapy in borderline or intermediate risk patients (5% to 7.5% 10-year cardiovascular disease risk). Based on current AHA/ACC guidelines, computed tomography calcium scanning for further refinement of cardiovascular risk in borderline or intermediate risk patients would be indicated and reasonable. In this case, the patients 10-year cardiovascular risk is 7.2%, indicating the borderline-intermediate risk category. The patient also has the risk enhancing factor of a family history of early cardiovascular disease. Therefore, computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT - 75571) is likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage. Patients without cirrhosis who have failed prior therapy with interferon regimens are recommended to be re-treated with Harvoni for 12 weeks. These guideline 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. In the ION-2 trial, non-cirrhotic patients who had failed peginterferon regimens demonstrated 94% sustained virologic response with Harvoni. Additionally, treatment of patients before they progress to cirrhosis is advantageous. A prospective study of 820 F0-F1 patients reported 93% 15-year survival in treated F0-F1 patients versus 88% in untreated patients. This patient is ineligible for alternatives that require high daily pill count due to pill dysphagia. For these reasons, the requested Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Overturned

Findings:  The physician reviewer found On 3/15/18, the patient weighed 133.4 pounds and had a body mass index (BMI) of 25.6. The patient continued to have chronic suicidal ideation with no intent or plan. The patients vital signs were stable, and the patient was medically stable. The patient has a distant past of self-harm at the age of 16 by cutting her arms with a razor blade. She continues to struggle with purging and restricting her diet. The patient is motivated for treatment. The patient was previously treated in 2017 and continues to require services to stabilize her condition. For these reasons, the requested PHP services are medically necessary for treatment of this patients behavioral health issues.  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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested for a treatment regimen for treatment of her pancreatic cancer.   Findings:  Three physician reviewers found that only 15% of patients with pancreatic adenocarcinoma have resectable tumors. This patient had superior mesenteric vein invasion which is one criterion that rules out resection. She appears to have very good performance status so the goal at this point would be to use a chemotherapeutic regimen that would give her prolonged survival. The Physicians Data Query offered by the National Cancer Institute recommends that all newly diagnosed patients be considered for clinical trials because current chemotherapy offers low objective response rate. A meta-analysis has been performed in which older 5-FU regimens have been compared to best supportive care and they have found that chemotherapy does offer a survival benefit (see Yip, et al.) But, no one regimen has emerged that provides prolonged survival so current recommendations can involve chemoradiotherapy, chemotherapy alone with 5-FU, chemotherapy alone with Gemzar (gemcitabine), or chemotherapy combination adding an agent to Gemzar (see Sultana, et al.). Combinations with gemcitabine have not provided any clear survival advantage over gemcitabine alone except for one trial where there was a modest advantage to gemcitabine/erlotinib combination (see Moore, et al.). Even so, this amounted to median survival of 6.37 months for those receiving the combination versus 5.91 months for those receiving gemcitabine alone.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female with left acetabular posterior wall fracture, right ankle fracture, odontoid process fracture, and right wrist fracture. She was transferred to a skilled nursing facility (SNF) on 11/24/04 for physical therapy to improve transfer. She is non-weight bearing in both lower extremities and has a halo device. The records indicate non-weight bearing of right lower extremity is to continue through 1/13/05. The patient has been recommended for restorative nursing activity as of 12/10/04. She wishes to receive additional SNF services. The Heath Plan has determined further SNF services are not medically necessary for treatment of the patients medical condition. Review of the submitted clinical information indicates the patient does not meet medical necessity criteria for SNF services. There is insufficient evidence that the requested services are likely to provide benefit and restoration of function. Patients such as this patient (i.e., non-weight bearing status) generally undergo limited rehabilitation courses until their orthopedic issues resolve. Based upon the information provided, the patients injuries preclude significant benefit from physical therapy until her bones are able to tolerate weight bearing. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested for the Liberty Pelvic Floor Stimulator for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that there is long-standing discussion regarding pelvic floor stimulation, biofeedback, magnetic stimulation and conservative therapy (e.g., Kegel exercises) for outcomes of treating pelvic floor symptoms. There is no good data, however, showing the role or place for these therapies and how they are to be used effectively. Bo and colleagues concluded that, Training of the pelvic floor muscles is superior to electrical stimulation and vaginal cones in the treatment of genuine stress incontinence. After a thorough review of the available peer-reviewed medical literature, I find it appropriate to conclude that the role of a pelvic floor stimulator in this setting has yet to be determined. As such, it has not been demonstrated that the disputed device was likely to be result in a better outcome for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested the medication Zetia for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that there is no documentation provided which demonstrates that Zetia is medically necessary for this patient. While the patient does require therapy to achieve an LDL lower than 130 by NCEP criteria, there is no evidence that he has tried therapy with a water-soluble statin (e.g., Pravachol) to see if he can achieve his LDL goal without the side effects of myalgias. Thus, the patient should undergo a trial of therapy with a formulary water-soluble statin prior to consideration of Zetia.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nourish Pediatric Formula meal replacement. Pediatric Nourish meal replacement is a plant-based, gluten-free, corn-free, soy-free, casein-free formula made with real food ingredients designed for nutritional management of children with special medical needs, including failure to thrive, and G-tube dependence. It is recognized by the Centers for Medicare and Medicaid Services as an enteral formula for both tube and oral feedings and is produced in an FDA/USDA registered facility.Here, the patient has severe failure to thrive as a complication of her complex congenital heart disease and multiple surgical repairs. She is dependent on GJ tube feeds for nutrition and after fundoplication has continued to have retching and vomiting, even after trials of multiple elemental pediatric formulas and medications.  Nourish has been the only formula that she tolerates, and this formula currently provides her with 100% of her nutrition that is delivered via GJ tube. Nourish is thus a life-sustaining treatment for this patients failure to thrive and it is a medically necessary treatment.Final Result: The reviewer determined that the requested items 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 pediatric endocrinology 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.