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

A 46-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he 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 was taken to the operating room for an exploratory laparotomy and lysis of adhesions based on a CT scan of his abdomen. The scan demonstrated dilation of the small intestine. The colon, however, contained material on this study. This is incompatible with a complete small bowel obstruction in which the small bowel would be dilated with the collapse of the small and large intestine, distal to the obstruction. A patient may have a partial or incomplete small bowel obstruction which is characterized by dilated loops of small bowel with some material in the distal intestine. However, there are other conditions which may cause dilated loops of small bowel as well, such as intestinal pseudo-obstruction and ileus. Based on the documentation provided, it is not possible to confirm the patients diagnosis. However, even if the patient by history and physical was suffering from a partial small bowel obstruction, emergency surgery was not necessary as standard treatment protocol calls for the use of a naso-gastric tube for intermittent suction and bowel rest, as a majority of patients will respond to conservative treatment. Furthermore, the evidence provided does not demonstrate that the patient was experiencing symptoms of sufficient severity to cause a prudent layperson to conclude that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to his health, impairment in bodily functions or serious dysfunction of a bodily organ or part. The patient presented with a chronic condition and had been having intermittent abdominal pain over an extended period. The patients lab data revealed a normal complete blood count and chemistry analysis. His vital signs were normal. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to seek emergency medical attention.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive and receptive language impairment with delayed acquisition of language skills. Consistent with the recommendations in the clinical literature, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 51-year-old female enrollee has requested authorization and coverage for continued intensive outpatient program (IOP) level of care services (five days per week) for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that The records provided for review document that this patient has not been a danger to herself or others and she has not demonstrated self-harm urges or behaviors. She continued to have urges to weigh herself and over exercise, while episodes of bingeing had decreased significantly. She has been medically stable and not orthostatic, as well as psychiatrically stable to the extent that she does not require IOP services five days per week. She has developed insight into her behavior, and has been described as an active and engaged participate in her treatment plan. There has been no acute worsening or development of new symptoms. All told, continued IOP level of care services (five days per week) are not medically necessary for treatment of this patients behavioral health issues. 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 with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade infusions administered every five (5) weeks. The U.S. Food and Drug Administration (FDA) approves the use of Remicade for the treatment of chronic severe plaque psoriasis, psoriatic arthritis, and ulcerative colitis. The FDA approved dosage is at eight-week intervals. In this case, the patient is being prescribed both Skyrizi and Remicade at five-week intervals. It is unusual for a patient to be treated with both medications in tandem. Given that the submitted documentation does not reflect a reason why both Skyrizi and Remicade are being prescribed, or why the standard eight-week dosing regimen is insufficient, the requested medication is not medically indicated. Therefore, Remicade infusions administered every five (5) weeks are not medically necessary for the treatment of this patient.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 dermatology 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 48-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of her bipolar disorder. Findings:  Three physician reviewers found that it is clear from the submitted clinical history that this patient is significantly burdened by her psychopathology. However, despite this patients need for symptom relief, there is little evidence VNS will be any more effective for her than conventional therapies. Concern regarding VNS as a treatment modality began with the approval process in early 2005. Despite FDA approval of VNS, the efficacy studies to date have not yielded unequivocal data in support of VNS over placebo. When VNS was approved by the FDA in July 2005, it concluded a process that was marked by two reversals of the decision. Final approval was met with surprise by many psychiatrists and the controversy has continued. The source of the controversy lies with the efficacy data. The FDA requires two randomized, double-blind, placebo-controlled trials that prove a proposed treatment is statistically superior to placebo. In the case of the VNS approval, both of these pivotal studies had serious design and methodology problems that left many scientists wondering what the data actually meant.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for administration of intravenous morphine 8 to 10 mg daily for a duration of two to four days, once or twice per month. The Centers of Disease Control and Prevention guidelines state, Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards recommends, Opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and nonpharmacological options have not been effective. Maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met.In this case, the patient has had a recent episode of pyelonephritis and was being treated with intravenous antibiotics along with intravenous morphine for pain control. The provider notes stated that the antibiotics were being changed due to bacterial sensitivities and that her kidney function had normalized. The provider notes stated that intravenous morphine was no longer indicated and that the patient was again able to use Toradol for her chronic kidney pain. There is no mention in national guidelines recommending the regular prescribing of intravenous opioid medication for outpatient use. Intravenous pain medications are used in supervised hospital settings and not for outpatient use. If the provider determines that opioid medication is indicated, an oral formulation could be used. The records show that the patient has not seen an in-Plan pain management provider in over ten years. Based on the available records for review and current guidelines, the requested medication regimen is not medically necessary. Therefore, administration of intravenous morphine 8 to 10 mg daily for a duration of two to four days, once or twice per month is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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 reimbursement for the bilateral digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the bilateral digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lupkynis (voclosporin) 7.9 mg capsules. The records provided for review document that this patient has a history of biopsy proven glomerular disease in SLE. The patient has reportedly failed treatment with numerous agents including prednisone, CellCept, Cytoxan, and Plaquenil. The patients provider has recommended treatment with Lupkynis, which is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with refractory nephritis. Since this patient has failed multiple standard first-line therapies, treatment with Lupkynis is appropriate for management of her lupus nephritis (Rovin, et al.; Clarke). Therefore, the requested Lupkynis (voclosporin) 7.9 mg capsules are medically necessary for treatment of this patient. 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 subspecialty certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old female has requested rental of a continuous passive motion machine for treatment following total knee replacement.  Findings:  The physician reviewer found that the use of a CPM machine postoperatively is routine and standard of care following total knee replacement generally. The device is utilized in the immediate postoperative period in the hospital and at home after discharge. It is normally used for anywhere up to four weeks postoperatively. In this case, it was prescribed for approximately three weeks, which was medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for deep sedation (D9222) and excision of a benign lesion, up to 1.25 cm (D7410) for tooth #14.The submitted documentation does not support that the requested services are medically necessary. The submitted radiographs do not demonstrate a lesion on or adjacent to tooth #14, however, an appeal note states that a cone beam computed tomography (CBCT) radiograph showed a cyst on the palatal aspect of tooth #14. Clinical differentiation can only come from a microscopic evaluation and does not change the treatment involved. These lesions are typically an integral part of the approved extraction of tooth #14. As such, debridement of the excision site is an integral part of the extraction process. In this case, the submitted radiographs and records do not demonstrate that the requested excision of benign lesion for tooth #14 requires a stand-alone procedure and would not be an integral part of the extraction process for removal of tooth #14. Tooth #14 shows no complex condition which would indicate anything other than a routine extraction. Therefore, the requested excision of benign lesion, up to 1.25 cm (D7410) for tooth #14 is not medically necessary to treat the patients medical condition.With regard to the patients request for coverage for deep sedation, the extraction of tooth #14 and excision of a benign lesion constitute treatment of a chronic condition. The submitted records do not demonstrate extenuating clinical conditions, and no medical compromise is described that would necessitate general anesthesia. Under these circumstances, general anesthesia would be administered solely for the convenience of the patient and treating doctor, and not as a matter of medical necessity. Accordingly, the requested deep sedation (D9222) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed doctor of dental surgery who 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left ankle. As noted in the medical literature, MRI provides an accurate method of observing and diagnosing injuries of the ligaments of the ankle, osteochondral fractures, articular cartilage injuries, and degenerative conditions. Clinical conditions that can present as posterior ankle pain include posterior ankle impingement, Achilles tendon and medial flexor tendon pathology, posterior subtalar tarsal coalition, sinus tarsi, and tarsal tunnel syndrome. This patient sustained an inversion injury to the left ankle, which has resulted in chronic ankle pain despite arthroscopy and debridement of the talus. X-rays have reportedly been negative. Thus, additional diagnostic studies are indicated for further evaluation of his chronic pain to help guide further treatment. Therefore, the requested MRI of the left ankle is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction assisted protein lipectomy (SAPL). This patient presents with right leg lymphedema that has not improved despite conservative therapy. The patient previously underwent total hysterectomy and bilateral salpingo-oophorectomy with removal of 22 lymph nodes in 2009, with lymphedema since 2010. Treatment has included manual lymph drainage and custom compression garments. Due to the failure of conservative therapy, persistent pain and associated symptoms including cellulitis, the requested SAPL is medically necessary for treatment of this patient. Moreover, the requested procedure is reconstructive in nature. The SAPL will address the patients abnormal condition and improve function as well as provide a more than minimal improvement in the patients appearance. All told, the requested SAPL is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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

The parent of a three-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on the available medical literature, the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 recommends speech therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. The authors concluded that, Individuals with mild autism should also receive adequate assessments and appropriate diagnoses.In addition, to speech and language deficits, the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. In support of the need for occupational therapy, studies have shown benefits that prevent deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Thus, speech therapy and occupational therapy are standard of care modalities for patients with autism.