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

Nature of Statutory Criteria/Case Summary: A 19-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that The patient had one prior suicide attempt at the age of 16. The patient was not hospitalized at that time. The patient had an extensive psychological evaluation which noted that the patient was not cutting or threatening suicide. The provider recommended dialectical behavior therapy (DBT) and cognitive behavioral therapy (CBT). The patient underwent a suicide assessment at which time the patient did not report any thoughts of suicide. The patient had a bright affect and had a pleasant mood. She did not have auditory or visual hallucinations or delusions. The patient was cooperative with staff and was interactive with peers. Overall, the records indicate the patient was stable and was a candidate for treatment in a less restrictive treatment setting as an outpatient. Therefore, the RTC services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Upheld

The patient is a 50-year-old female who has a skin tag on her left lower eyelid. She indicates the skin tag changes in size, itches all the time, and sometimes is very painful and tender. Her physician referred her to an opthalmologist who recommended she undergo removal of the skin tag. The Health Plan has denied this request indicating the procedure is cosmetic in nature and not medically necessary.Skin tags are common, benign, and seldom require removal for other than cosmetic purposes. Though the eyelids are an area subject to skin cancers, no evidence has been presented demonstrating that an excisional biopsy is warranted at this time. Furthermore, there is no evidence the skin tag results in a functional impairment. As such, there is no medical indication for the requested procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested chiropractic services for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was being treated for generalized back, neck, and head pain. The records show no objective, measurable, and functional gains in daily living or reduction of medication. There was no documentation submitted regarding basic history or examination findings and no long-term or short-term treatment goals. Evidenced-based guidelines generally recommend a trial of therapy for chronic pain. However, the provider has failed to provide a sufficient history or examination to document the patients condition or history of chronic pain.  All told, chiropractic services were not medically indicated for the treatment of this patient. 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 chiropractic care 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 authorization and coverage for Otezla (apremilast) for treatment of the enrollees psoriasis vulgaris. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Her history of breast cancer precludes the use of immunosuppressive agents in her treatment, including injectable biologics and cyclosporine.  She lives at too far a distance from the clinic to feasibly undergo in-office phototherapy.  She reports having tried therapy with methotrexate, but developed widespread hyperpigmentation on her skin.  Given the treatments tried and failed, in the context of a breast cancer history rendering some treatments contraindicated, it is medically reasonable to consider therapy with Otezla.  Otezla is an oral, small molecule inhibitor that is U.S. Food and Drug Administration (FDA) approved for treatment of psoriasis and is not considered to be immunosuppressive.  All told, Otezla is medically indicated for the 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 physician 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

A 50-year-old female enrollee requested authorization and coverage of hyperbaric oxygen therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees hip pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 48.8, this patient meets nationally accepted criteria for weight loss surgery. The resultant weight loss that the patient is likely to achieve with weight loss surgery is likely to provide substantial benefit for her co-morbid conditions. The fact that the patient has not participated in a two-year medically managed weight loss program prior to surgery should not preclude her from being considered an appropriate surgical candidate. The patient has attempted diet and exercise without success. Further attempts with conservative methods are not likely to achieve adequate results for this patient. As such, bariatric surgery is medically appropriate and indicated in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet per day, for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 32-year-old female enrollee requested a spinal cord stimulator for medical treatment of her pelvic and buttock pain with a diagnosis of interstitial cystitis.   Findings:  The physician reviewer found that the records document that the patient has failed to receive any reduction in pain or improved quality of life with conservative therapy and medications. Surgery is not considered an appropriate treatment option for chronic interstitial cystitis. In this case, where the patient has intractable pain and urinary frequency despite medication and failed conservative therapy, spinal cord stimulation is supported in the medical literature . Spinal cord stimulation was found to reduce pain, improve quality of life, and reduce analgesic consumption, as well as allow some patients to return to work with minimal significant adverse events. For these reasons, the requested spinal cord stimulator is supported as medically necessary in treating this patients chronic pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Synvisc 16 mg/2 ml injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Additionally, the literature indicates that if there is significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. The medical literature indicates that viscosupplementation is safe and effective. Additionally, these injections allow for delay of total knee replacement and are more effective than corticosteroid injections. In this patients case, the patient has been diagnosed with osteoarthritis of the left knee. He reports severe pain with functional limitation in work activities. Prior viscosupplementation injection have provided good pain reduction and improvement in function for six to eight months. This patient had failed to adequately respond to other conservative treatment including medications, physical therapy and corticosteroid injection. Therefore, the requested Synvisc 16 mg/2 ml injections are 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 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: Upheld

A 62-year-old female enrollee has requested for general anesthesia services rendered during the endoscopic procedure performed for evaluation of her gastrointestinal symptoms. Findings:  The physician reviewer found that MAC, when used in the setting of endoscopy, is medically appropriate when an individual has an intolerance to standard sedatives. It is also indicated in the presence of underlying co-morbidities that contraindicate against conscious sedatives. However, in this patients case there was no noted intolerance to conventional sedatives. Further, the medical records do not document any unusual medical circumstances that would warrant the use of MAC sedation versus conscious sedation. Therefore, there were no circumstances in this case requiring the use of MAC. The Health Plans denial was thus appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 14-year-old female who was diagnosed with an unresectable mixed brain tumor (ependymoma, grade II and low-grade glioma) in December 2004. The patient underwent surgical exploration at that time, and complete resection was not possible due to the vascularity of the tumor with bleeding issues. In addition, the patient was found to have metastatic disease with several spinal cord lesions. The patient subsequently began therapy with antineoplaston. Follow-up CT in March 2005 demonstrated stable or slightly increased tumor size with a large suprasellar mass and right parasellar tumor. The patient underwent vetriculoperitoneal shunts on both sides for treatment of hydrocephalus. An MRI in April 2005 demonstrated marked progression of the tumor.The patient has been re-evaluated by an in-plan pediatric neurosurgeon and has obtained a second opinion at USC. Both physicians felt that surgical resection would not be beneficial given the metastatic disease and would subject the patient to significant neurologic risks. The patient was seen at UCLA where a pediatric neurosurgeon recommended surgical resection under MRI guidance, and the pediatric oncologist recommended postoperative radiation and chemotherapy, likely using carboplatin.At issue is whether tumor resection performed at UCLA is medically necessary for treatment of the patients medical condition.The patient is a 14-year-old female with metastatic mixed brain tumor. UCLA physicians have recommended surgical resection under MRI guidance followed by radiation therapy (cranial and spinal) along with chemotherapy of carboplatin. A recent MRI demonstrated significant progression of the tumor, which was initially unresectable in December 2004.Review of the submitted clinical evidence reveals the tumor is clearly unresectable based on the MRI of April 2005, and there remains evidence of spinal metastases. The tumor was very vascular during the initial operation in which a total resection was abandoned due to bleeding issues. Therefore, it is unclear what benefit intraoperative MRI would offer since the tumor is unresectable and anatomic boundaries were not the limitation to complete resection in December 2004. Furthermore, given the progression of disease and the local extent of the tumor, it is unclear what benefit debulking therapy will offer the patient. It is not known whether the goal of this procedure is palliation of the current neurologic symptoms or to provide some benefit to the subsequent chemotherapy and radiation therapy. In any event, the surgical treatment recommended by the UCLA physician is not significantly superior to the services offered by the in-plan provider, nor does there seem to be any direct benefit provided to the patient, though significant risks will be incurred.Accordingly, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested Intravenous Immune Globulin (IVIG) for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. This patients clinical features are consistent with chronic inflammatory demyelinating polyneuropathy (CIDP). CIDP is diagnosed based on the clinical picture and is supported by electrodiagnostic testing and potentially elevated spinal fluid protein. This patients diagnostic testing has also been consistent with CIDP. Intravenous Immune Globulin is commonly used for treatment of CIDP and there is ample medical literature and clinical guidelines that supports this treatment. In conclusion, based on the reasons provided above, the requested Intravenous Immune Globulin is medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services and ultrasound for treatment of an emergency medical condition. Findings:  The physician reviewer found that the urgent care services and ultrasound were not necessary for treatment of an emergency medical condition. The patient presented to urgent care with reports of a right breast lump. In this case, there was no emergent intervention indicated based upon the clinical presentation. A work-up for a breast lump was indicated and could have been scheduled at a facility in-network. An emergent breast ultrasound was not indicated in this clinical setting. All told, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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:    An enrollee has requested services with a plan psychologist once per week and services with a plan psychiatrist once per month for treatment of his behavioral health conditions. The physician reviewer found that in this patients case, it is not medically necessary for him to see a plan psychologist at a frequency of once per week.  However, it is medically necessary that he received services from a plan psychologist.  This patient requires an updated treatment plan.  Input from a psychologist regarding formulation, level of care determination and the appropriateness of non-pharmacologic interventions is indicated in this case.  Thus, an initial comprehensive diagnostic psychological evaluation for purposes of clinical assessment and treatment planning is medically necessary.  The need for additional psychologist visits beyond the initial diagnostic evaluation will depend upon the exam findings.  Per the medical records, it is not medically necessary for the patient to see a plan psychiatrist at a frequency once per month.  However, it is medically necessary for him to see a plan psychiatrist.  The patients suicidality risk has been adequately assessed and has not been an issue of clinical concern during this episode of treatment.  The patient has been difficult to engage and has a history of not promptly following through with treatment recommendations.  However, from the psychiatric perspective, the patient has no significant safety concerns and has been stable on his current medication regimen for several months.  Frequent monitoring of response, as often as every other week, has been shown to improve results during acute phase treatment.  However, the method of monitoring can vary and may include office visits, phone calls, secure electronic correspondence or discussion with other professionals involved in the case such as case managers, nurses, health technicians and therapists.  Considering the patients chronicity and stability of the current medication regimen, quarterly office visits with monthly telephone calls in between appointments due to the prescription of a stimulant is medically indicated. Final Result: The reviewer determined that a portion of the requested services 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   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 fecal calprotectin testing for evaluation of the enrollees diarrhea. Findings:  The physician reviewers found that fecal calprotectin testing has been recognized for several years as an effective way to assess the likelihood of a patient having inflammatory bowel disease need for sedation with a colonoscopy. Once diagnosis is made, fecal calprotectin is also a tool for monitoring disease activity, as it correlates with endoscopic measures of intestinal inflammation. For this patient, the provider noted that at the time that the test was ordered that he would not recommend a colonoscopy if the calprotectin results were normal. All told, the fecal calprotectin testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing 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 reviewers number one, two, and three are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and 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.