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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of her behavioral health condition. Findings:  The physician reviewer found that The documentation submitted does not support the medically necessity of the services at issue in this clinical setting. This patient did not have suicidal or homicidal ideations or psychosis. The records indicate that she had continued symptoms of poor interpersonal skills and periods of intense emotions but she had not engaged in any self-harm behaviors. She was not displaying any significant or severe behavioral problems during her stay. The records demonstrated that she requires additional treatment to further improve her social functioning, impulsive behaviors, and mood. However, it appears that she no longer needs the restrictiveness of a residential psychiatric treatment facility as she has stabilized enough, over the several weeks of residential care at the facility to transition to a less  restrictive setting. The treatment goals listed by the residential treatment center could be accomplished on an outpatient basis. While the treatment of the patients interpersonal skills will likely require longer-term treatment due to her autism spectrum disorder diagnosis, it would not be expected that these interpersonal skill deficits would be resolved during residential treatment. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry. The guidelines recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Children should be treated in the setting that is least restrictive and disruptive to their lives. The medical literature supports inpatient or residential treatment for children who have not responded to efforts at outpatient level of care.  Moreover, there is strong data to suggest that there are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  Studies have shown that treatment outside of a residential setting are effective and are as beneficial as RTC programs.  Final Result: The reviewer determined that the services at issue were not and 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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for facial laser hair removal for treatment of her gender dysphoria.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient has been diagnosed with gender dysphoria. The presence of male pattern facial hair is contributing to the patients gender dysphoria. Thus, facial laser hair removal is medically necessary for treatment of her medical condition. Further, facial laser hair removal is considered reconstructive in this setting. The presence of facial hair in a female would be considered abnormal and is referred to as hirsutism. The `abnormal` hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. The requested laser hair removal procedure will create a more normal feminine facial appearance. Further, the requested laser hair removal procedure can provide substantial improvement in the appearance of the patients terminal hair. As such, the requested service is considered reconstructive in this clinical setting. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.  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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation and treatment with a regenerative medicine specialist. Findings:  The physician reviewer found that records document treatment with fluoroquinolone therapy in the past with current complaints of headaches, brain fog, generalized body aches, sleep disturbance, and irritable bowel symptoms. The patient expressed concern for the possibility of fluoroquinolone toxicity. Fluoroquinolones have been associated with reported increased risks for development of tendinopathy and peripheral neuropathy. Some data suggests that the risk of fluoroquinolone-associated tendon pathology is higher in certain populations such as patients older than 60 years of age, those on concomitant corticosteroids, solid organ transplant recipients, and patients with renal insufficiency. Treatment includes discontinuation of fluoroquinolone therapy and care for the resultant musculoskeletal issues. One case report described improved symptomatology following intravenous antioxidants, amino acids, an elimination diet, and probiotics for suspected fluoroquinolone toxicity. However, the authors acknowledged that on review of their findings, it was ultimately unknown whether the patients symptoms were caused by the fluoroquinolone medication. Based on this patients records, there is no indication for consultation with a regenerative medicine specialist for this suspected condition. There is no expectation of clinical benefit with any therapy beyond usual care for arthralgias or other musculoskeletal symptomatology that can be directed by a non-regenerative medicine specialist. Moreover, there is a lack of medical literature or clinical trials demonstrating the clinical benefits intravenous antioxidant therapy and amino acid therapy over placebo for this patients condition. For these reasons, the requested consultation and treatment with a regenerative medicine specialist is not medically necessary for evaluation and 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 physical medicine and rehabilitation 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: An enrollee has requested reimbursement for inpatient mental health hospitalization. The submitted documentation does not support the medical necessity of the services in issue. The submitted documentation reflects that on the dates of service in issue, the patient was cooperative, denied suicidal ideation or homicidal ideation, and denied hallucinations or delusions. The patient was cooperative with the treatment program and his vital signs were within normal limits. There was no indication of withdrawal from illicit drugs or alcohol. There is no indication in the patients medical records of any basis for 24 hour nursing care. The record does not explain why an inpatient hospital level of care was medically necessary. Therefore the inpatient mental health hospitalization provided on the dates of service in issue was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services in 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 patient has requested authorization and coverage for Norco 10/325 mg. The Centers for Disease Control and Prevention (CDC) have issued guidelines for the use of opioid medications in patients with non-cancer related pain for initiation, monitoring and discontinuation. Specifically, the CDC guidelines state that opioids should only be considered when non-opioid and non-pharmacologic interventions have been ineffective. The CDC noted that when utilized,  opioids should be used at the lowest dose that is effective and minimizes opioid-related complications and risks. In addition, opioid management should include consultation and urine toxicology screening and an opioid use contract is recommended between the provider and the patient. Per the CDC, providers should use caution when prescribing opioids at any dosage and should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME) per day. The Medical Board of California (MBC) has also provided guidance on the use of opioids which includes balancing the benefit of treatment with opioids against the potential risks. Applying the CDC and MBC guidelines to this patient, any potential benefit with opioid treatment is outweighed by the risks and does not support continued treatment with opioids. This patients records document a history of bilateral shoulder pain that has been managed with Norco. However, there is a lack of documentation that the patient has fulfilled the requirements for continued opioid pain management. The provider noted that multiple urine drug screens have been positive for tetrahydrocannabidiol (THC). Moreover, the patients providers have recommended treatment with physical therapy, cortisone injection, and cognitive behavioral therapy rehabilitation in lieu of continued opioid therapy. Given these findings, the requested Norco 10/325 mg is 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 physical medicine and rehabilitation 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: Upheld

This patient is a 44-year-old female with low back pain and muscle spasms. She is being treated with medications and facet blocks by a neurologist. The Health Plan indicates that the patient does not require neurology specialty care and can be appropriately treated by a pain management specialist. At issue is whether ongoing neurology specialty care is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. This patients chronic low back pain would be more appropriately managed by a pain specialist with fellowship training in pain management and spinal blocks than by a neurologist. This is no clinical indication for neurologic care based on the information provided. The services offered by the Health Plan are medically reasonable and appropriate for this patient. Therefore, I have determined the requested specialty care is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has requested authorization and coverage for Synvisc One injections in both knees. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the data on safety and efficacy remain inconclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the remaining options are limited. In this case, the patients available treatment options are limited. Treatment with NSAIDs and corticosteroid injections did not provide the patient substantial relief. A total knee arthroplasty in the presence of mild narrowing of the joint spaces is not a recommended course of treatment. As such, Synvisc One injections in both knees are likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested facet rhizotomy for treatment of her back pain.  Findings:  Two physician reviewers found that Geurts and colleagues concluded that there is moderate evidence that radiofrequency facet denervation is more effective for chronic back pain than placebo. It would be appropriate to perform rhizotomy for the patients back pain as long as facet arthropathy was proven to be a pathological cause either through physical examination and/or MRI with negative evidence for nerve root compression. Pevsner and colleagues performed a retrospective study to assess the role of radiofrequency in the treatment of mechanical spine pain. They evaluated 122 patients who underwent radiofrequency heat lesion of the medial branch nerves for mechanical spinal pain (low back pain, thoracic pain or cervical pain). Following the study, the authors reported that radiofrequency is a safe and partially effective procedure for mechanical back pain. This patients pain appears to be due to thoracic nerve root compression given her positive response to the transforaminal epidural steroid injection. However, pain due to nerve root compression is less likely to benefit from thoracic radiofrequency ablation. Consistent with these findings, the requested procedure is not supported as likely to be more beneficial for treatment of this patients medical condition than standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested Boniva for the treatment of her osteopenia. Findings:  The physician reviewer found that this patient has the diagnosis of osteopenia and therefore has a risk for osteoporosis. The Health Plan provides coverage for a bisphosphonate. Fosamax is effective in the prevention of osteoporosis as well as vertebral, nonvertebral and hip fractures in patients at risk for this condition. Fosamax is within the standard of care. The proposed alternative, Boniva, offers no better efficacy than Fosamax and furthermore has been shown to be ineffective in reducing hip fractures. Therefore, Boniva is not medically necessary for this patients care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home infusions of Panzyga for four days every two months for one year. This patient presents with a history of multiple sclerosis. The patients current medication regimen includes Tecfidera twice daily with continued symptoms. Her provider recommended treatment with Panzyga, which is intravenous immunoglobulin (IVIG) therapy. There has been considerable research on the use of IVIG for the treatment of patients with multiple sclerosis. However, there is a lack of sufficient data to suggest that IVIG treatment provides substantial benefit when compared to currently available therapies. There is a paucity of data from prospective randomized controlled clinical trials reporting on the long-term safety and efficacy of Panzyga for multiple sclerosis. Therefore, the requested home infusions of Panzyga for four days every two months for one year are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested home infusions of Panzyga for four days every two months for one year 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 medication 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 neurology 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:  An enrollee has requested authorization and coverage for Euflexxa injections for the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the options are clearly limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: An enrollee has requested reimbursement for intensive outpatient program services. Findings:  The physician reviewer found that in this patients case, the records support the medical necessity of a portion of the services at issue. The patient had a formidable addictive illness, and comorbid depressiveness and anxiety, which demanded chemical dependency specialty care. Per community standards, he progressed from more restrictive to less restrictive treatment settings during the episode of care as the acuity level lessened.  At the time of transition to intensive outpatient program level of care, the patient had made meaningful therapeutic progress. He was motivated for recovery.  He was able to identify effective treatment modalities and potential barriers unique to his case. His family was supportive. The treatment notes indicated that the patient was actively engaged in evidence-based treatment. However, the summary letters notwithstanding, there were no subsequent medical records submitted for review such as progress notes, physician statements or interpretative summaries articulating the medical necessity of the setting. The patient had nearly three months of sobriety. He was motivated for sobriety and better educated on his illness and treatments. He was not having a prolonged withdrawal syndrome, and he was not experiencing significantly impairing psychiatric symptoms. He was stable on psychotropic medications. The records do not demonstrate that comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate. In sum, intensive outpatient program services were medically necessary, but not the dates without evidence. Final Result: The reviewer determined that 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 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.