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

Expedited Review: The parent of a transgender male enrollee has requested authorization and coverage for subcutaneous bilateral mastectomy procedure. The Health Plan has denied this request indicating that the requested procedure is not medically necessary and is not reconstructive in nature for treatment of the enrollees gender dysphoria. 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. Nature of Statutory Criteria/Case Summary: Based on the documentation provided, this patient has gender identity disorder and is documented to be an appropriate candidate for gender affirmation surgery. The patient reported that his dysphoria prevents him from going out in public. In this patients case, having normal appearance of the breasts, for a male, is the ultimate goal. While the Health Plan criteria provides that the patient should be 18 prior to undergoing surgical intervention, chronological age is not as important as the level of pubertal development. In this patients case, his breasts appear to be consistent with a teenage female. Testosterone has not resolved this patients breast enlargement.  Since the condition has not resolved, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  All told, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Thus, the subcutaneous bilateral mastectomy procedure is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested procedure is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. This patient has well documented gender dysphoria and his breasts are developmentally abnormal for a male. The patients breasts should be more consistent with adult male breasts. Further, the plan of surgery will improve function and create a relatively normal appearing male chest. The proposed surgery will provide more than a minimal improvement in the appearance of this patient. Therefore, in this patients case, subcutaneous bilateral mastectomy procedure is reconstructive in nature.Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lenvima 10 mg capsule. Findings:  The physician reviewer found that the request for Lenvima 10 mg capsule is  medically necessary for treatment of the patients medical condition. The patient presents with metastatic hepatocellular carcinoma with progressive disease. The phase III SHARP trial shows that sorafenib treatment may result in survival advantage over supportive care alone by three months. Capecitabine has a response rate of 25% in one study where it was used as a single agent . Most cytotoxic chemotherapies have comparable response rates when tried against hepatocellular carcinoma, a typically chemo-resistant tumor ). Lenvima is a multi-functional tyrosine kinase inhibitor with activity against VEGFR. Phase I and II trials have shown safety and efficacy against hepatocellular carcinoma . As such, Lenvima is a reasonable next step therapy and medically necessary for treatment of the patients hepatocellular carcinoma. 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 medical 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acupuncture services provided. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who has a history of headaches.Findings:  According to the medical research, acupuncture is considered effective for migraines and headaches. Acupuncture plus routine care in patients with headache were associated with marked clinical improvements compared with routine care alone. There is consistent evidence that acupuncture provides additional benefit for treatment of acute migraine attacks. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered as a treatment option for patients willing to undergo this treatment. However, in this patients case, it is unclear how many sessions of acupuncture have already been rendered. There is support in the medical literature for the acupuncture sessions already performed. Accordingly, acupuncture services provided were medically necessary for the treatment of this patients medical condition. With regards to future visits, this should be requested based on documented progress and/or improvement as well as the total number of rendered acupuncture visits. Such documentation is currently lacking in this case. For these reasons, acupuncture services provided were medically necessary for the treatment of this patients medical condition. However, future services have not been demonstrated as medically necessary, at this time.Final Result: The reviewer has determined a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  The reviewer is board certified in oriental 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 32-year-old female enrollee has requested for allergen specific blood testing for evaluation of her medical condition.   Findings:  Two physician reviewers found that IgG food testing is considered to be experimental in large part because the significance of positive IgG tests to foods is not known. Standard evaluation for suspected food allergies would include skin testing to the suspect foods and/or IgE testing (as this is not considered experimental in nature) for foods, but not IgG testing. A review of the testing performed on this patient shows that she was tested for a large number of foods, and that the testing consisted of both IgE and IgG tests. However, the results did not distinguish between these two types of tests.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female has requested past and prospective coverage for inpatient psychiatric treatment of her behavioral health issues.  Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness. This patient presented as a distressed, mentally ill patient.  The patients records throughout the hospitalization demonstrate the patient could have been safely and effectively treated in a less restrictive setting as of the date in question. The American Psychiatric Association (APA) recommends the psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. The determination of an appropriate setting for treatment should include consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. Although acute hospitalization was appropriate to fully treat this high risk patient, the medical records fail to justify the necessity of inpatient acute care through a date at issue. Specifically, the extent of psychotropic medication management did not necessitate the inpatient setting. Further, the acute suicidality that justified the admission had resolved per both physician and nursing documentation. The psychiatrist noted that the patient was a little less depressed and not suicidal, psychotic or cognitively impaired with a better form of thought. Nursing commented that the patient was feeling better, visible in the milieu, and denied suicidal ideation. The patient posed no imminent threat to self or others and was not gravely disabled due to her psychiatric illness. However, she remained symptomatic and treatment in an intermediate setting, such as residential services specializing in evidence-based psychotherapies for patients PTSD and eating disorders was indicated to consolidate her treatment gains, reduce morbidity and lessen the chance of re-admission. Based on the documentation provided, and review of relevant medical relevant literature, discharge to a less restrictive treatment setting such as outpatient therapy on the date at issue would have been safe, reasonable, and consistent with the APA treatment guidelines. Thus, the services provided from the date at issue, and forward were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided as defined in Health and Safety Code section 1317.1, subdivision (a)(2)(A) and subdivision (k)(1) as set forth below. The Health Plan has denied this request indicating that the services at issue were not emergency medical services.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.In this case, the patient was stable, motivated and without any major psychiatric symptoms at the time of admission. He was not an immediate danger to himself or others, nor was he immediately unable to care for himself due to mental health conditions. The services at issue were not necessary for treatment of an emergency psychiatric medical condition. Thus, the patient did not receive emergency psychiatric services. Final Result: The reviewer determined that the patient did not receive psychiatric 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 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

A 45-year-old female has requested coverage for spinal fusion surgery at L1-2 and a planned 3-day hospital stay for treatment of her lumbosacral neuritis.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a history of chronic low back pain. She has not had any localizing pain referable to the L1-2 segment. She has abnormalities at the L1-2 segment and at T12-L1, but there is also a disc bulge at L2-3 with facet arthropathy at that level as well as at L3-4, and a broad-based disc bulge at L5-S1. With regard to the requested surgery, the patient does not have any defined L1-2 radiculopathy (Tarulli and Raynor). In addition, she has not had L1-2 identified as her defined pain generator. For these reasons, she does not meet the Milliman criteria or recommendations from Bambakidis and colleagues for a lumbar fusion.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endometrial biopsy. As noted by the American College of Obstetricians and Gynecologists (ACOG), the primary role of endometrial sampling in patients with abnormal uterine bleeding is to determine whether carcinoma or premalignant lesions are present, although other pathology related to bleeding may be found. Moreover, the ACOG states that endometrial sampling also should be performed in patients younger than 45 years with a history of unopposed estrogen exposure (such as seen in obesity or PCOS [polycystic ovarian syndrome]), failed medical management, and persistent abnormal uterine bleeding. The ACOG further noted that, the decision to histologically evaluate the endometrium should be based on symptomatology and clinical presentation. On review of the patients documentation, there is a lack of an indication for an endometrial biopsy. The patient is premenopausal and has not reportedly failed medical management. In addition, she does not have any evidence of unopposed estrogen exposure or persistent abnormal uterine bleeding and she is not obese. Further, an ultrasound showed a normal endometrial stripe. All told, the requested endometrial biopsy is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 patients parent has requested authorization and coverage for increase of hours of 1:1 applied behavioral analysis (ABA) therapy from 15 hours to 22 hours per week. Findings:  The physician reviewer found that requested services fail to meet multiple elements of Papatola and Lustigs definition of medical necessity. According to Papatola and Lustig, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Per the records provided for review, this patients provider has listed several goals that do not address the symptoms of autism. These goals include housekeeping, feeding pets, cleaning surfaces, and cooking. Although each of these goals requires the patient to work on his ability to follow directions, the goals do not explicitly address the core symptoms of autism such as socialization and communication deficits, or repetitive behaviors. Thus, the requested services do not meet criterion (b). In addition, the provider identifies that the reason for the increase in support hours is for the patient to access additional support while school is closed. However, the services need to be indicated due to the severity of the patients symptoms, not because the patient is more available for treatment. An increase in hours when school is unavailable fails to meet criterion (d), as the increase is due to convenience of the patient. Moreover, the requested increase in 1:1 ABA hours is not consistent with the Council of Autism Service Providers (CASP) recommendations. The CASP highlight the requirements for focused levels of treatment intensity typically includes 10-25 hours per week 1:1 ABA therapy. Focused ABA is appropriate for a limited number of functional skills. Given that several of this patients goals identified in the authorization request are not medically necessary, and low rates of problem behaviors are documented, the current 15 hours of 1:1 ABA per week is appropriate. For these reasons, the requested increase in hours of 1:1 ABA therapy from 15 hours to 22 hours per week is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, 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 authorization and coverage for intraoperative radiation therapy (IORT).Findings:  Three of the three physician reviewers found the requested IORT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. While Correa and colleagues note equivalent outcomes in patients who undergo standard radiation therapy and IORT, this patient would fall into the cautionary group for the use of IORT based on her age. IORT is not recommended in patients who fall into the cautionary group. Likewise, the American Society of Breast Surgeons recommends partial breast radiation in patients older than age 45. Therefore, given this patients age, IORT is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested growth hormone therapy, Genotropin (somatropin) injection, for treatment of the enrollees short stature. Findings:  The physician reviewer found that review of the submitted documentation reveals the patient has extreme short stature with normal weight for height ratio, poor growth velocity, low IGF-1 level, and a delayed bone age. Although her peak GH response on provocative GH testing was normal, she meets standard criteria, as established by the Pediatric Endocrinology Society for treatment with GH. Provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets at least three of the above criteria and for these reasons, growth hormone, Genotropin (somatropin injection) is medically necessary for treatment of the patients medical condition.  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 pediatrics with sub-specialty certification 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Qulipta 60 mg tablet, and (2) Trudhesa aerosol solution 0.725 mg/actuation, 1 mL nasal spray (12 mL per 28 days). Scuteri and colleagues report that calcitonin-gene related peptide (CGRP) antagonists play a fundamental role in migraine pharmacotherapy. Rustichelli and colleagues describe atogepant (brand name Qulipta), an orally active small molecule, as a potent, selective antagonist of the CGRP receptor and as the only gepant authorized exclusively for episodic migraine prophylaxis in adults. Qulipta is also an option for women of childbearing age, as it has a very short half-life in comparison to other medications that block CGRP activity such as Aimovig. This allows a much faster elimination time from the body if necessary. In this case, given the patients headache frequency, a prophylactic headache medication is medically indicated. The current medical literature supports the use of the requested medication. Therefore, (1) Qulipta 60 mg tablet is medically necessary for the treatment of this patient.In this case, the records note success with the patients use of Ubrelvy tablets as an abortive agent. While they have a history of nausea, the records do not indicate that nausea is limiting the patients use of Ubrelvy tablets. In a narrative review of dihydroergotamine (brand name Trudhesa), Silberstein and colleagues report that nasal spray formulation exhibit low bioavailability and high variability that limits its efficacy. The authors further note that of 19 clinical studies, some results have yet to be published, while other studies are currently underway. The nasal spray approach may be appropriate in the setting of significant nausea, which is not documented in this case. Therefore, (2) Trudhesa aerosol solution 0.725 mg/actuation, 1 mL nasal spray (12 mL per 28 days) is not medically necessary for the treatment of this patientFinal Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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.