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

A 28-year-old female enrollee has requested emergency services for treatment of her 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 presented with pain in her foot for several weeks after stepping on some glass. She denied fever, swelling, vomiting, or any other symptom associated with an infectious process. Her symptoms had not recently changed or worsened. Foreign bodies that have been present in the soft tissues for long periods of time do not generally pose an immediate threat to life or limb. They are usually cared for on a non-emergent basis and are seldom removed in the Emergency Department. Since this patient was not experiencing any sudden decompensation in her condition and was not suffering fever, swelling, or any other acute sign of infection, her symptoms do not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a myPath melanoma assay.Findings:  The physician reviewer found that The myPath melanoma assay is a gene expression profiling (GEP) test used to classify melanoma pathology specimens by risk of recurrence. As a prognostic test for cutaneous melanoma, it is considered investigative. However, it may be beneficial when used to classify atypical spitz or spitzoid tumors, helping to differentiate benign nevi from cutaneous melanoma, including atypical Spitz tumors. Swetter and colleagues state, Diagnostic molecular techniques are still largely investigative and may be appropriate as ancillary tests in equivocal melanocytic neoplasms, but they are not recommended for routine diagnostic use in cutaneous melanoma. These include comparative genomic hybridization, fluorescence in situ hybridization GEP, and (potentially) next-generation sequencing. These tests may help to differentiate benign nevi from cutaneous melanoma, including atypical Spitz tumors. Therefore, the myPath melanoma assay was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the myPath melanoma assay at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: A 21-year-old female enrollee has requested reimbursement for the residential treatment center (RTC) services provided from October 4, 2017 through November 7, 2017. Applying the Level of Care Utilization System (LOCUS) criteria, the RTC services provided were not medically necessary. The patient presented with moderate risk of harm (score 3) as the patient does not have a history of suicidal ideation or prior suicide attempts. The patient demonstrated moderate functional impairment (score 3) with a significant deterioration in her ability to fulfill responsibilities. The patient has significant co-morbidity (score 3) with ongoing substance use despite negative consequences as well as a history of anxiety and depression. The patients recovery environment was moderately stressful (score 3) as the patient was recently homeless. The patient had a supportive environment (score 2) as her parents were supportive and willing to participate in family therapy. They were also willing for the patient to live in their home if the patient remains sober. The patients treatment history has resulted in equivocal results (score 3) as the patient was in an intensive outpatient program (IOP) and continued to use substances after this treatment. The patient was engaged and motivated in treatment (score 2) and the patient was compliant with medications. This evaluation gives the patient a composite score of 19 which is consistent with IOP level of care services. The patient would have also benefitted from a sober living environment. Thus, although the patient continued to require treatment for her opioid use disorder, this could have been accomplished at a less restrictive environment. Therefore, the RTC services provided were not medically necessary for treatment of this patients behavioral health issues. 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: Overturned

The patient has requested reimbursement for Inpatient mental health treatment. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with medically monitored residence-based services. However, the patients score for risk of harm supports treatment at the medically managed residence-based services, such as inpatient level of care. Given the severity of the patients illness, the inpatient mental health treatment was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 21-year-old female enrollee has requested Botox injections for the treatment of her migraines. Findings:  Three physician reviewers found that Botox is widely used by headache specialists in patients with chronic migraine who have failed multiple standard therapies. Its use is supported in the medical literature, which suggests that Botox has been shown to be effective and safe for the treatment of chronic migraine in a large Phase II, and 2 large Phase III studies. This patient has very frequent, disabling headaches, consistent with migraine. As chronic migraine is defined as more than 15 headache days per month, this patient can be classified as having chronic migraine. She has been under the care of various providers, including two neurologists, and has been tried on a litany of medications without significant relief. Given the presence of this patients intractable and severe headaches unresponsive to conventional medications, Botox is more likely to be more beneficial for treatment of her medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested gene panel testing for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the patient has optic nerve atrophy. A thorough ophthalmologic and genetic work-up has been performed with no identification of an etiology. There is no reported family history of similar problems. A chromosomal test showed duplication of 11q22.1 of unknown significance and the patients father is unaffected. The pediatric ophthalmologist and geneticist suggested further genetic sequencing studies to provide further insight. However, in the absence of a family history of inherited optic atrophy, additional testing will not provide information that would change the natural history, management, or course of treatment in the patient. Thus, the requested gene panel testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in ophthalmology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for unilateral extremity study, transcatheter embolization and left foot ultrasound. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided were not necessary for treatment of an emergency medical condition. Congenital vascular malformation of the foot when symptomatic presents with pain and swelling. Surgical and endovascular therapy are appropriate therapy for the lesions. Direct injection therapy has also been shown to be effective.  In this case, the medical management provided was clinically indicated. However, the services performed were not emergent. In sum, the documentation submitted for review does not support emergent services were provided on that date. For the reasons provided, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in vascular 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 for treatment of the enrollees developmental language and speech delay.  Findings:  The physician reviewer found that children with speech delays can be readily and successfully treated (Law, et al). Goorhuis-Brouwer and Kniff specifically dealt with speech-delayed children, such as this cognitively normal patient, and pointed out that such normal children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, most often required and subsequently benefitted from speech therapy (Emanuel, et al; Buschman, et al).   Speech therapy is medically indicated in this child.  The medical community standard for a three-year-old verbally delayed child, such as this patient, is to continue speech therapy.  The requested speech therapy is medically necessary for six months, followed by a speech re-evaluation.  If the patient demonstrates improvement, but still has significant delay in both expressive and receptive speech, therapy should be continued for an additional six months.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested deep brain stimulation for treatment of his Parkinsons disease. Findings:  The physician reviewer found that deep brain stimulation (DBS) is a U.S. Food and Drug Administration (FDA) approved treatment for advanced Parkinsons disease. The medical  literature review states From the evidence available, we conclude that surgical management of [Parkinson disease] PD alone or in combination with medical therapy results in greater improvement of motor symptoms and quality of life than medical treatment alone. There is evidence to support the use of DBS in less advanced PD and that it may be appropriate for earlier stages of the disease than for which it is currently used. The improving short and long-term safety profile of DBS makes early application a realistic possibility. Moreover, the medical literature reports that waiting too long to use DBS, may be associated with a significantly lessened response. Given the young age of this patient, his rapidly progressive disease, current use of an extremely high dose of medication, and presence of significant fluctuations despite very frequent dosing, DBS is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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

A male enrollee requested residential behavioral health treatment center services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that considering the patients severe mental illness and treatment history, a brief course of care at the residential setting would have been inadequate. After initial programming, the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting and discharge would have likely resulted in undue morbidity, relapse and prompt readmission to the acute level of care. Additionally, the services provided were for active treatment, and reasonably expected to improve his condition and prevent a more serious episode of illness. Further, the duration of services was consistent with community practice standards. Considering the clinical presentation and peer-reviewed literature, the residential behavioral health treatment center services were medically necessary for treatment of the patient behavioral health conditions.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ankle replacement surgeryfor treatment of the enrollees ankle painFindings: The physician reviewer determined that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with continued right ankle pain and associated functional limitations in weight-bearing activities. He is status post right ankle fracture at age 18, right retrocalcaneal exostectomy with Achilles tendon debridement in January 2016, and Achilles tendon lengthening on 7/12/16. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. He has been diagnosed with post-traumatic right ankle arthritis with x-rays on 5/01/17 showing early ankle arthritis per the orthopedic surgeon. He also has severe right Achilles tendinosis/tendinitis. There is no compelling rationale presented to support the medical necessity of ankle replacement for 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 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 Harvoni for eight weeks for treatment of her chronic hepatitis C virus genotype 1a and 1b.  Findings:  Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. The guidelines note that treatment duration of eight weeks can be considered in treatment-naive patients without cirrhosis who have a baseline viral load less than 6 million IU/mL. Since this patient is treatment-naive and has a viral load of less than 6 million IU/mL, the requested eight week course of Harvoni is medically necessary.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three 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: The patient has requested authorization and coverage for Ofev. Ofev may be recommended for the treatment of patients with idiopathic fibrosis and scleroderma related interstitial lung disease. In this case, there is no documentation to support a diagnosis of scleroderma interstitial lung disease. The patient underwent evaluation in a scleroderma clinic in January 2020. At that visit, the provider noted that the patient does not have evidence of pulmonary fibrosis or parenchymal lung disease as evidenced by review of high-resolution lung computed tomography (CT) scan performed in December 2019. The scleroderma specialist did not recommend any medications for the treatment of lung disease, but did recommend pulmonary rehabilitation. Given these findings, the requested Ofev is not medically necessary for 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 internal medicine with subspecialty certification in rheumatology 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.