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

A female enrollee requested lumbar laminectomy for medical treatment of her progressive degenerative disc disease (DDD). Findings:  The physician reviewer found that the records indicate that this patient has chronic back pain. However, she has no symptoms or signs of lumbar radiculopathy (Tarulli and Raynor). The criteria for fusion from the Milliman Care Guidelines (MCG) and National Imaging Associates (NIA) include lumbar radiculopathy, sciatica, cauda equina syndrome, pseudarthrosis, and spinal stenosis with progressive neurologic condition or neurogenic claudication after failure of six months of conservative care including physical therapy, ESI, chiropractic care, and cognitive behavioral therapy. All told, the requested lumbar laminectomy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an 18-year-old male enrollee have requested Adult Psychiatric Acute inpatient level of treatment for the treatment of the enrollees condition. Findings:  The physician reviewer found that whether the patient suffers from a psychotic Major Depression or Schizoaffective Disorder, it is clear that he was no longer actively suicidal. Residential or intensive outpatient treatment would appear better suited to helping him with these sorts of struggles than inpatient treatment.  Overall, I find that inpatient treatment was not medically indicated and recommend upholding the Health Plan denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication OxyContin 80mg tablet, quantity 360 tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain. At issue in this case is whether the requested OxyContin 80mg tablet, quantity 360 tablets is medically necessary for treatment of the enrollees medical condition.The CDC Opioid Guidelines recommend less than 90mg morphine equivalents per day. The patient has a history of severe chronic neck pain that has been refractory to multiple conservative measures including physical therapy; aquatic therapy; multiple cervical fusions; cervical rhizotomies; and over 25 epidural injections to the cervical spine. The prior medication trials are not outlined. Despite these treatments, the patient continues to report severe pain. However, the request for OxyContin 80mg quantity 360, 3 tabs by mouth every 6 hours is beyond the norm for treatment of non-malignant chronic pain. This dose is much greater than the CDC recommendation for opioids and therefore not medically necessary.Final Result: The reviewer determined that the requested medication is 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 subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for infusion treatments of vedolizumab (Entyvio) at a dose of 140 mg (6 mg/kg/dose) at zero, two, and six weeks, then every eight weeks. The recommended medical therapies for the management of this patients moderate-to-severe ulcerative colitis include adalimumab, ustekinumab, and either certolizumab or golimumab. On review of the patients records, treatment with adalimumab, certolizumab, and golimumab is not recommended. Based on the U.S. Food and Drug Administration (FDA) approval, the patients age does not support treatment with biologics other than infliximab and adalimumab. Given the patients primary non-response to infliximab, treatment with a different anti-tumor necrosis factor (TNF) agent is not likely to yield positive results. Furthermore, there is a lack of data on the use of ustekinumab or vedolizumab in the patients in the pediatric population. In a multicenter cohort study of 52 young patients with inflammatory bowel disease, including 22 with ulcerative colitis, 42% of patients with previous anti-TNF failure were in remission at week 14 following treatment with Entyvio (Singh, et al.). Given these findings, the requested infusion treatments of vedolizumab (Entyvio) at a dose of 140 mg (6 mg/kg/dose) at zero, two, and six weeks, then every eight weeks are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment level of care services for treatment of the enrollees depressive disorder and polysubstance dependence.  The physician reviewer found that although episodic treatment is often necessary for patients afflicted with psychotic illness and substance use disorders, the services provided                                                                                                                                                                                                                                                                                                                             were not medically necessary for treatment of this patients medical condition. There was no psychiatric evaluation, psychosocial assessment, history and physical, treatment plan or integrated summary justifying the necessity of the placement. The progress notes that were provided did not describe behaviors, symptoms, or treatment interventions that require a 24-hour medically-supervised setting. The patient was anxious. Her bupropion was discontinued for concern that its noradrenergic effects were exacerbating her anxiety. She had limited insight and mild to moderate paranoia, but neither negatively impacted her thought processing, which was described as coherent, linear, and goal-directed. Further, the patient was not depressed, psychotic, delusional, suicidal or homicidal. There was no mention of symptoms or sequelae from her amphetamine dependence. Subsequently, the patients mental status examination was identical while she was actively engaged in her treatment and noted to be eating and sleeping well. The provider recommended cross-tapering the patients antipsychotic medication from risperidone to lurasidone due to concerns of weight gain and fatigue. However, this type of modification can be safely performed in less restrictive settings. In sum, the services provided at the residential level of care were not medically necessary for treatment of this patients medical condition. 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 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 enrollee is requesting authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The enrollee was evaluated for lower back pain and reported it began 12 years ago. The enrollee participated in physical therapy but his pain persisted. Neurology ordered a magnetic resonance imaging scan, which revealed a disc herniation. He has been using conservative treatment for his pain, but has had occasional flare-ups. The enrollee participates in home exercise, which has improved his pain. However, the enrollee reports worsening pain over the last four to five months described as sharp in nature, with occasional radiation to the posterior right hip. The pain is exacerbated by sitting, transitioning from sit to stand, and exercising. It is worse in the morning. The physician indicated the enrollees symptoms are consistent with lumbosacral radiculitis, secondary to disc herniation at L3-L4; degenerative disc disease and disc desiccation; facet arthropathy, and myofascial pain. The provider recommended outpatient physical therapy and ordered a magnetic resonance imaging scan. Medical records indicate the enrollee reported subjective weakness in his legs and pain on Valsalva maneuver, but denied any numbness or tingling, change in bowel or bladder control, unintentional weight loss, or night sweats. The physical exam shows tenderness to palpation of the paraspinal muscles on the right at L3-4, positive flexion, adduction, and internal rotation, and positive flexion, abduction, and external rotation on the right; and a negative slump test and supine straight-leg raise. The magnetic resonance imaging scan shows paracentral disc herniation, left greater than right, at L3-4, and degenerative disc disease with disc desiccation and facet arthropathy. The diagnoses were lumbosacral radiculitis, secondary to disc herniation at L3-4, degenerative disc disease, facet arthropathy and myofascial pain. The enrollees physical exam and history appear consistent with degenerative disc disease and facet arthropathy. The enrollee does not have any red-flag signs suggestive of an acute process, such as worsening pain, cauda equina syndrome, or symptoms worrisome for an underlying tumor. The enrollees exam is more consistent with a myofascial syndrome, such as piriformis syndrome; sacroiliac joint dysfunction, and facet arthropathy. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injections for the right knee. The records provided for review document that this patient sustained right knee internal derangement. Imaging revealed posterior horn medial meniscus with displaced meniscal tissue adjacent to the medial tibial spine, moderate chondromalacia patella with areas of subchondral bone marrow edema and cystic change, and large knee joint effusion. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and platelet-rich plasma (PRP) injections. The patient reported improved pain with PRP injections. The provider has recommended additional PRP injections. In the medical literature, researchers concluded that there are some data supporting PRP for well-selected patients in the treatment of osteoarthritis, ligament, tendon, and meniscal injuries of the knee. However, there is a paucity of evidence from prospective randomized controlled trials supporting the long-term safety and efficacy of PRP over standard available therapies for use in this clinical setting. Researchers concluded that there are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing meniscal repair with versus without PRP augmentation. Based on the available evidence, patients undergoing meniscal repair with PRP experience similar clinical outcomes at midterm follow-up when compared with conventional meniscal repair. The authors concluded that additional studies are needed to determine the efficacy of meniscal repair augmented with PRP. Therefore, the requested PRP injections for the right knee are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested PRP injections for the right knee are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute level of care services for treatment of the enrollees behavioral problems. Findings:  The physician reviewer found that the patient did not demonstrate suicidal or homicidal ideation. The patient was no longer significantly aggressive or impulsive in behavior, nor was a danger to self or others, and was ready to resume in what was a highly contained environment with full time caregivers. The patient was cooperative and medically tolerated her medication regimen. In addition, a highly developed discharge plan was in place including multiple full time caregivers. The patient's care became custodial in nature. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dental services provided on the basis that the services were emergent. Emergency dental and oral surgery services are those necessary to stabilize an acute injury to sound and natural teeth. The provided history and radiographs show the teeth involved, have had a long history of dental procedures including prior failed root canal treatments and crown placements. The patient first presented for the recurrence of pain in this area approximately months prior to the dates of service at issue. Given the approximate history of symptoms in the teeth involved, the extractions performed during the period at issue were shown to be for treatment of a chronic dental condition. The progress notes provided confirm the subsequent bone grafting procedures were in preparation for future tooth replacement with dental implants, again a dental procedure for tooth replacement resulting from a chronic rather than an acute condition. Based upon the information set forth above, the patient history and medical records provided demonstrate that the services provided were services for treatment of a chronic dental condition and not emergency medical services as defined by California law.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dentistry 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 enrollees parent is requesting authorization and coverage for the prescription medication Genotropin for idiopathic short stature and mild constitutional delay with no chronic medical problems.  Findings:  The physician reviewer found that the enrollees pediatrician initiated a work-up for short stature. Growth records show that her heights were at, or slightly below, the 3rd percentile since age three and a half and her weights were between the 15th and 45th percentile. Her height was 2.39 standard deviations below the mean and her growth velocity was 3.84 cm per year.  Growth hormone therapy was started at age eleven. Nutropin was tried initially, but the enrollee experienced discomfort with injections and this was changed to Genotropin.  While on growth hormone therapy, her growth velocity is 7.44 cm per year.  According to the record, the enrollee experiences stinging and discomfort with Nutropin; a well-known side effect that is usually transient.  There is no mention of a severe allergic reaction, such as hives or swelling.  The medical literature indicates mild stinging and discomfort are not contraindications to Nutropin. There is insufficient evidence in the record of a reaction so severe as to require a change in medication. Further, the medical literature does not support Genotropin as more effective than Nutropin (NuSpin) for this enrollees condition. There is an absence of head-to-head studies in the medical literature demonstrating outcome differences between products.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatrics and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested  coverage for speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that it is within the standard of care in the medical community to continue to provide this patient speech therapy as recommended by his provider. There is strong evidence in the peer-reviewed medical literature supporting speech therapy in similar speech-delayed patients. Law and colleagues meta-analysis concluded that, overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Similarly, Buschmann and colleagues reported that the 2-year-old population with language delay benefitted from speech therapy. Goorhuis-Brouwer and Kniff demonstrated that cognitively intact patients are ideal candidates for successful speech therapy. This patient is developmentally and intellectually normal except for his significant delay in expressive speech. As measured by his performance on the RITLS, his expressive speech improved from a 6-month level to a 12-month level since he started speech therapy. For these reasons, it is medically necessary that this patient receive individual speech therapy sessions twice weekly as recommended by his provider.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Contrave TAB.The enrollee has a history of obesity, class I, with a body mass index (BMI) of 30-34.9, papillary thyroid carcinoma and post-surgical hypothyroidism. Her weight increased from 158 pounds (BMI 29.01) to 172 pounds (BMI 31.55). While this weight gain could be attributed to her hypothyroidism, as lab results showed elevated TSH this was not currently the case. Lab results showed a TSH level of 0.57 (within the normal range of 0.40-4.50), and the provider documented the enrollee was euthyroid, and should continue on the current thyroid replacement regimen of levothyroxine. Despite the enrollees euthyroid state, records indicate her weight gain could not be controlled with a low carbohydrate diet and lifestyle modification. She was interested in medication to assist with her weight loss, and the provider prescribed Contrave. Review of the current literature on obesity management indicates pharmacotherapy for obesity can be considered for patients who have a body mass index (BMI) of 30kg/m2 or greater. Since this enrollees BMI is 31.55, refractory to lifestyle modifications, including diet and exercise, and her obesity is not the result of poorly controlled hypothyroidism, she is a good candidate for weight loss pharmacotherapy. The FDA-approved drugs for treating obesity include Naltrexone-bupropion. However, alternatives, such as amphetamine-dextroamphetamine and Armodafinil are not. Amphetamine-dextroamphetamine is a generic name for Adderall, which is a controlled substance, schedule II drug with a high potential for abuse. It is an amphetamine-based stimulant drug used to treat Attention Deficit Hyperactivity Disorder (ADHD) and narcolepsy. Armodafinil is an FDA-approved medication for the treatment of narcolepsy, obstructive sleep apnea/hypopnea, and shift work sleep disorder. This medication too, is not listed as one of the FDA-approved drugs for treating obesity. In a 2016 systematic review and meta-analysis study of the association of pharmacological treatments for obesity with weight loss and adverse events, the safety and efficacy of Contrave (Naltrexone-bupropion) was evaluated. Based on this study, when compared to placebo, Contrave was associated with achieving at least 5% weight loss at 52 weeks. While this study provides evidence for the safety and efficacy of Contrave for the treatment of obesity, there is no such study and support for the other alternative medications, including amphetamine-dextroamphetamine and Armodafinil. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism 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.