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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. Findings:  The physician reviewer found that MRI of the cervical spine may be appropriate for the evaluation of patients with prior cervical spine surgery, new or increasing non-traumatic cervical or neck pain, or cervical radiculopathy. Current evidence-based medical criteria for cervical spine MRI generally includes emergence of physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or clarification of anatomy prior to an invasive procedure. This patient presents with cervicalgia, paresthesia of skin, pain in upper arm, and abdominal pain. Physical examination revealed complaints of chronic joint pain throughout her body. The pain is worse in her posterior neck with burning, numbness, and tingling sensations that radiate from her neck down to both arms and hands. She reports a similar burning sensation in her bilateral armpits. There is bilateral flank pain that radiates to the front of her abdomen. The provider noted that physical examination of the neck revealed positive posterior cervical spine tenderness to palpation, including along the paraspinal muscle in this area. There were no motor or sensory deficits noted. Detailed documentation is not evident regarding objective clinical findings of myotomal weakness, reflex loss, or sensory deficits to support an indication for further evaluation with MRI. In addition, trial and failure of recent, reasonable and comprehensive less invasive conservative care measures is not documented in the records provided for review. For these reasons, the requested MRI of the cervical spine is not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage of Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus. 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni. 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. For these reasons, the requested treatment with Harvoni for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. 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 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 31-year-old female enrollee has requested use of a continuous passive motion machine (CPM) for the treatment of her right knee, status post anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that although there is some evidence of benefit in the use of CPM in the early postoperative period after ACL reconstruction, these benefits do not appear to extend with use beyond the initial few days. After several weeks, no significant differences are found with CPM use. Controversy remains regarding the use and duration of use of a CPM device after ACL reconstruction. However, no advantage has been demonstrated for prolonged outpatient use of a CPM device. Thus, the patients use of a CPM machine for several weeks following surgery was not likely to result in an improved outcome.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male has requested coverage for dental surgery services provided on an emergent basis. Findings:  The physician reviewer found that the patient presented to his dentist with symptomatic left sided facial edema and symptomatic tooth #14. He was immediately referred to an oral surgeon whose findings were consistent with left maxillary vestibular and left infraorbital space abscess secondary to tooth #14. The patient underwent removal of the tooth with incision and drainage of the affected spaces the same day. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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.  The patient had a significant infection which was odontogenic in origin. It had spread beyond the alveolar process into the adjacent spaces. The patient also had significant clinical signs of infection which included fever and pain. The infection had progressed into a fascial plane that threatened adjacent structures. Left untreated, the patient was at risk for worsening of the infection with potential involvement of adjacent anatomical structures such as the orbit and cavernous sinus. Treatment goals for such an infection are to treat surgically with supportive care including antibiotic therapy. All told, the patients symptoms on the date in question met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or health and as such, would have sought immediate medical attention.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old male enrollee has requested for Botox injections for treatment of his temporomandibular joint (TMJ) disorder.  Findings:  Three physician reviewers found that there is sufficient literature to support the use of Botox in this clinical setting. The patient has tried multiple other regimens without sustained benefit. He has already tried Botox therapy with excellent results. Botox injections are medically appropriate for this patient and should be continued.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox 200 unit injections, 155 units every three months for treatment of the enrollee, who has a history of chronic headaches. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. The records indicate the patient has migraines and chronic daily headaches. However, the records do not describe in detail the features that would confirm the diagnosis of migraine, such as sensitivity to light and noise, or untreated headache duration of four hours or longer. Thus, chronic migraine cannot be confirmed in this patients case. Botox has been proven to be effective for chronic migraine, but is not supported for other headache types. Therefore, the requested Botox 200 unit injections, 155 units every three months are not medically necessary for the 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Nature of Statutory Criteria/Case Summary: Findings:  The physician reviewer found that a review of the submitted documentation does not support the medical necessity of the requested services. The records indicate the patient has undergone appropriate evaluation for gender dysphoria according to 2017 Endocrine Society clinical practice guidelines. Based upon the most recent documentation provided, the patient has taken hormonal treatment for reassignment to the male gender for approximately 20 months. The 2017 Endocrine Society guidelines state, Because some transgender male adolescents present after significant breast development has occurred, they may also consider mastectomy 2 years after they begin androgen therapy and before age 18 years.  In this patients case, the records demonstrate that he has not received hormone therapy for a full 24 months, and was not compliant with hormonal therapy as recently as December 2017. Thus, the patients hormonal treatment is not aligned with the most recent Endocrine Society mastectomy guidelines for adolescents. Further, the patients lack of compliance with hormonal therapy suggests that his maturity level and level of engagement are not consistent with the pursuit of gender reassignment surgery at this time. As such, the requested bilateral mastectomy to be performed on an outpatient basis is not medically necessary.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 child and adolescent psychiatry and expertise in treating gender dysphoria 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 patients parent has requested authorization and coverage for Protopic (tacrolimus) 0.1% ointment. There are limited evidence-based data guiding the treatment of necrobiosis lipoidica diabeticorum, especially in children. While corticosteroids are the mainstay of therapy, they can have long-term unwanted side effects. Necrobiosis lipoidica diabeticorum can lead to ulceration and even skin cancer if not treated. Researchers reported that Protopic is an effective treatment option for patients with refractory chronic ulcerated necrobiosis lipoidica who do not want systemic oral therapy. In addition, the available data support the efficacy of Protopic 0.1% ointment after treatment with short-term corticosteroids. This patient has a diagnosis of necrobiosis lipoidica. Prior treatment with Protopic 0.1% was successful and did not produce any unwanted effects. Alternatively, the patients condition flared after changing to the 0.03% formulation of Protopic. Given these findings, the requested Protopic (tacrolimus) 0.1% ointment is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested mediation 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 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 parent of an enrollee has requested reimbursement and authorization and coverage for Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day), and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week).In this case, there are anecdotal reports from the patient's parents and Visual Communication Analysis therapist that the patient's maladaptive behaviors have decreased, and his ability to identify letters has increased during the time that he has received Visual Communication Analysis. No plan for parent training is provided. Under these circumstances, the submitted documentation does not support that Visual Communication Analysis and Self-Determination Theory are medically necessary for the patient. Therefore, Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day) and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week) were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested osteopathic manipulative medical treatment from an osteopathic physician (DO) specialist for the treatment of her lymphedema. Findings:  The physician reviewer found that there is no evidence that osteopathic manipulation is more effective than the standard lymphedema treatments offered by the Health Plan in treating her mild persistent lymphedema, and therefore, it is not medically necessary. As stated in literature, the cornerstone of lymphedema treatment is compression garments, manual massage, skin care, and remedial exercises. Such services can be obtained from in-network providers.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Guardant360 biopsy free tumor sequencing test provided for evaluation of the enrollees lung cancer. Findings: The three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer are currently considered the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. For these reasons, the Guardant360 biopsy free tumor sequencing test provided was likely to be more beneficial than any available standard therapy. Final Result: The 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for food allergy testing services. Researchers note that the general approach to diagnosis of food allergy include modalities such as medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin E (IgE) measurements, and oral food challenges. Current medical literature does not support the inclusion of an assessment of immunoglobulin (Ig) G, IgA, IgE, IgM and IgG subclass levels in the work-up of an individual with food allergies. The quantitative immunoglobulins are usually measured in the work-up of immunodeficiency. Basophil activation testing and mast cell receptor activity values are not standardized and are not supported as being of value in a standard evaluation of a patient with food allergies. While testing IgE levels to specific foods in question may be part of a food allergy evaluation, an extensive array of blood tests that examine aeroallergen component IgE as well as food IgG4 testing is not of demonstrated benefit in the evaluation of food allergies. A complete blood count (CBC) with differential is not generally indicated for the evaluation of a food allergy patient. Therefore, food allergy testing services are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested food allergy testing services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services  are 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: Physician reviewer 1 is board certified in internal medicine and in allergy and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics and is 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

A 64-year-old female enrollee has requested for her skilled nursing facility care for treatment of her medical condition.    Findings:  The physician reviewer found that the patient did not receive skilled therapy and did not require skilled nursing services.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old female who has a history of stroke with right-sided hemiplegia and dysphasia. The results of a physical therapy evaluation in April 2005 indicated the patients rehabilitation potential is poor. A speech evaluation also performed in April 2005 showed moderate receptive/expressive aphasia with some improvement noted over previous evaluations. It was further noted the patient required moderate assistance in communication with potential to reach minimum assistance. A request has been made for additional physical and speech therapy. The Health Plan indicates the requested therapies are not medically necessary for the patients condition.Review of the submitted physical therapy evaluation of April 2005 reveals the patients rehabilitation potential is poor. Additionally, it appears there was an absence of significant response to the patients prior therapy. As such, there is no evidence the patients condition is likely to improve with additional physical therapy. However, based on the results of the April 2005 speech therapy evaluation, there is potential for improvement with regard to the patients ability to communicate. As such, an additional 12 sessions of speech therapy is medically reasonable and appropriate and should be authorized. The patient should be re-evaluated after the 12 sessions to determine if further therapy is likely to be beneficial. Accordingly, I have determined that although the requested physical therapy is not medically necessary for treatment of the patients medical condition, the requested speech therapy is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be partially overturned.