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

The patient is a 32-year-old female with a history of upper back pain and asthma. She consulted with a plastic surgeon who noted the anticipated reduction in breast size was not likely to alleviate her back pain. There is no evidence of intertrigo or bra strap grooving in the photographs submitted for review. The patient has requested authorization for reduction mammaplasty. This request was denied by the Health Plan citing a lack of medical necessity.The patients primary complaint is upper back pain. According to Gonzalez, et al, symptomatic macromastia is best defined as a pain complex in three or more anatomic areas. The incidence and severity of headache, neck pain, shoulder pain, back pain, breast pain and painful bra strap grooving in the group of patients with symptomatic macromastia was more than three standard deviations greater than in the age-matched control group. This patient has medically documented pain in only one area. Additionally, a breast reduction of 100 to 200 grams is minimal and below the 5th percentile on the Schnur Table, which would indicate the reduction is primarily for cosmetic reasons. The photographs provided do not show significant breast hypertrophy or bra strap grooving. Finally, after an evaluation of the patient, the consulting plastic surgeon did not believe the proposed breast reduction would significantly improve her back pain. For the reasons citied above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. 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 at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with ear pain and dizziness as well as abdominal pain. She admitted to dysuria. Her urinalysis was positive for leukocytes. Further laboratory testing was indicated to rule out sepsis. The patient received an ultrasound to rule out acute abdominal pathology. Although her ear pain was not acute, the patients abdominal pain required screening tests to rule out an abdominal emergency. Thus, the screening and evaluation to determine if an emergent medical condition was present. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in emergency 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: Overturned

A male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions.  In treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks. These new guideline recommendations are based on multiple randomized clinical trials.  Based on evidence of safety and efficacy in the published literature, Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47 year-old female who underwent a gastric bypass operation in 2000 at a weight of 348 pounds and a BMI of 57.9.  She lost about 135 pounds and then began to regain her lost weight. The patients current weight is 282 pounds, with a BMI of 46.9.   She has a large ventral hernia and is requesting a Lap Band procedure in order to lose weight and reduce the chance of hernia recurrence.  The Health Plan has determined that the Lap Band procedure is not medically necessary and therefore, has denied authorization and coverage for the procedure.The patient and her provider are requesting authorization for the Lap Band procedure in order to correct her weight regain and minimize the chance of hernia recurrence after surgical repair.  The patients surgeon indicated there is an 80% success rate with the gastric bypass operation.  The Buchwald study found only a 61.6% success rate for the gastric bypass and other published data showed even lower long-term success rates for the super morbidly obese patients with a BMI greater than 50.  The patients inadequate weight loss and weight regain following gastric bypass are not unexpected or surprising. The Obesity Surgery article referenced above is one of a very few articles that addresses the revision of a failed gastric bypass operation. Conversion of a proximal to a distal gastric bypass results in significant metabolic deraignment as the patients provider noted. There is no scientific data that demonstrates a long-term benefit to Lap Band placement in this situation. The notion that a more restrictive operation will promote further weight loss is not a scientifically proven fact. Based upon the information set forth above, I have determined 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: Overturned

The enrollee is requesting authorization and coverage for a custom foot brace (HCPCS codes L1951 and L2820). The enrollee has a history of diabetes. She was evaluated by her podiatrist due to complaints of bilateral leg numbness. She reported difficulty walking and  picking up her legs. The patient described symptoms of burning, tingling, and numbness at rest that have persisted for ten years. The podiatrist prescribed a custom dorsiflexed assist ankle foot orthosis (AFO) for her.  The Certified Prosthetist Orthotist (CPO) describes the enrollee as having a history of drop foot resulting from diabetes mellitus. She had not worn an orthosis previously. She requires a device that can hold up to her weight, ambulation, and activities of daily living. From assessing the enrollee and her gait pattern, the orthotist believes the Townsend Spry step spiral style carbon fiber ankle-foot orthotic (AFO) is the most clinically appropriate prefabricated AFO choice for her. A thermoplastic leaf spring AFO is inappropriate for this enrollee due to the deforming forces present during ambulation. The enrollees documented lower extremity musculoskeletal exam revealed 2/5 inversion and eversion bilaterally, and 0/5 dorsiflexion and plantarflexion bilaterally.  The physician reviewer found that her toes catch; causing her to trip and fall.  This has been going on for approximately 10 years and no conservative measures have helped.  The enrollee denies any orthotic or bracing treatments in the past. The podiatrist wrote an order for a dorsiflexed assisted custom AFO.  The CPO performed a detailed gait exam and muscle testing, which revealed left ankle weakness. The enrollee admitted to 23 falls in a three-month time span. The CPO trialed different types of ankle-foot orthosis (AFO) braces and determined a carbon fiber leaf spring AFO would result in decreased falls for the enrollee, while allowing her the most natural gait possible. The patients weight was a factor in the decision to proceed with this type of device.  A study showed both prefabricated and custom AFOs improved gait velocity, cadence, step length, and stride length in individuals with acute CVA. Individuals preference was for the custom-made plastic AFO over the prefabricated carbon AFO. Individuals felt more balanced and safe with the custom brace. Because documentation notes a failure of gait improvement in this enrollee with the different trials of prefabricated AFO braces, the custom AFO brace is necessary for her.
Appeal type: Urgent Care
Decision: Overturned

A 24-year-old female enrollee has requested emergency dental services. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention.  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. In this patients case, she presented with severe dental pain.  Given the diagnosis of irreversible pulpitis of several maxillary teeth, it is reasonable to assume that a prudent layperson would have sought immediate medical attention.  The patients severe pain would have likely affected her oral intake and left untreated would have placed the patient at risk for a significant risk for infection given the diagnosis of irreversible pulpitis. The patients symptoms during the dates of service at issue met prudent layperson criteria for emergency care. The services provided during this period were required to stabilize the patients condition and alleviate her severe pain which rose to the level of an emergency medical condition. The patients condition did not stabilize such that she no longer required emergency care until after the date of discharge.  A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize her health in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation for treatment of the enrollees thoracic pain. Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  Per the medical records, the dual medial branch tests were negative.  The documentation indicated that the pain increased with the second injection, and did not decrease.  The test showed that this approach would not benefit this patient.  There is a lack of support for the requested services in this clinical setting.  Therefore, the requested radiofrequency ablation is not likely to be of greater benefit than other treatment options. Final Result: The 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. Credentials/Qualifications: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned

A 50-year-old male enrollee requested venous blockage repair (venous angioplasty) for medical treatment of his medical condition.  Findings:  Three physician reviewers found that in this case, the services at issue were indicated to prevent the thrombus from dislodging and going to the lung and enhance IVC flow. For these reasons, the venous angioplasty performed was likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested for artificial disc replacement for treatment of his cervical disc disease.   Findings:  Three physician reviewers found that although artificial disc replacement represents a novel surgical technique in the management of symptomatic disc disease, there is insufficient peer-reviewed evidence and randomized controlled trials reporting on its long-term safety, efficacy and its capacity to preserve motion and prevent adjacent-level disease comparable to or superior to that of traditional anterior cervical discectomy and fusion (ACDF). ACDF remains the standard of care surgical procedure for this condition according to most spine societies and spine surgeons.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested weekly individual psychotherapy services for treatment of her depression. Findings:  The physician reviewer found that the American Psychiatric Association (APA) guideline states that during maintenance treatment, patients with bipolar disorder are likely to benefit from a concomitant psychosocial intervention including psychotherapy that addresses illness management. The APA further notes that the primary goal of psychotherapeutic treatment is to reduce distress and improve the patients functioning between episodes as well as decrease the likelihood and severity of future episodes. Moreover, this patients records demonstrate that weekly psychotherapy has helped reduce her hypomanic and depressive symptoms as well as maintain safety. During this time when she has elected to stop medication treatment for the safety of the pregnancy, the use of weekly individual psychotherapy services is supported as medically necessary for treatment of this patients medical condition from the date indicated and forward.
Appeal type: Medical Necessity
Decision: Upheld

This case involves a 53-year-old female who suffers from migraine headaches for which she takes Maxalt and she takes Zofran for the comorbid nausea. The patient wishes to continue taking Zofran for her nausea. The patient indicates that she is also suffering from depression. She has been prescribed Adderal for an unknown reason.  The Health Plan has denied authorization and coverage for Zofran because it is only approved for nausea due to cancer treatment.This patient is taking Maxalt for her migraines, which is known to cause nausea.  The patient has not fully explored alternative medications for treatment of her migraines or her comorbid nausea according to the records provided. A trial of Zomig nose drops or another migraine medication that does not cause nausea might be beneficial. Reglan is an effective and well-tolerated anti-nausea medication. Depending on the frequency of the patients migraine headaches, prophylactic treatment with Depakote might be indicated. Depakote may also help with mood stabilization. As it appears there are other medications available that are likely to be effective for this patient, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old woman with a long-standing history of neck pain. The patient has undergone treatment with traction, chiropractic, and physical therapy. The patient has requested authorization for additional physical therapy visits. The Health Plan indicates the patients condition has significantly improved since she began physical therapy. Therefore, the Health Plan has determined that additional physical therapy is not medically necessary for treatment of the patients neck pain.Review of the submitted medical records shows the patient has reached a plateau in terms of range of motion. As of 12/11/03, strength was noted as 5/5 and sensation was noted as independent. There has been no reported change in functional status since 10/2/03 and pain complaints are unimproved since that time. Hence, the patients progress has reached a plateau. It appears the patients therapists request for physical therapy once per week is for the purpose of maintaining the patients condition. The patient has already been instructed in a home program. Given the patients long history of neck pain it is not anticipated that she will benefit from additional physical therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a mandibular advancement device for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the medical necessity of the requested device in this clinical setting. In February 2017, the patient has had a sleep study showing an apnea-hypopnea index (AHI) of 5.4.  An AHI of 5 to 15 indicates mild obstructive sleep apnea. The patient describes excessive daytime sleepiness causing trouble focusing. Physical examination demonstrated a blood pressure of 147/91, indicating a hypertensive state. The Health Plan noted that in order for an oral device to be considered medically necessary, the patient should first try treatment with a machine that helps breathing when she is sleeping, such as continuous positive airway pressure (CPAP) device. In this patients case, there is documentation of intolerance to CPAP manifested by claustrophobia and latex allergy. The current medical evidence supports the requested device for the treatment of this patient. All told, the requested mandibular advancement device is medically necessary in this patients case. Final Result: The reviewer determined that the requested device 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 dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested Acceptance Commitment Therapy (ACT) by a trained therapist who can provide the therapy out in the field for the treatment of his panic disorder. Findings:  The physician reviewer found that this patient has not been tried on an adequate trial of an antidepressant. While it is noted that he experiences side effects, it appears from the email correspondence reviewed in the records that he benefits from close monitoring and frequent contact. Such an approach, with the goal being for the patient to receive a therapeutic level of an antidepressant for an adequate period of time, would be medically appropriate and is likely to be more effective than the requested ACT therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an upper endoscopy with monitored anesthesia care. The submitted documentation supports the medical necessity of the requested upper endoscopy. Clinical guidelines recommend an endoscopy for investigation of upper gastrointestinal symptoms (such as heartburn or dyspepsia) when those symptoms are refractory to proton pump inhibitor therapy taken properly for four to eight weeks without response. American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. American College of Gastroenterology guidelines for gastroesophageal reflux disease recommend endoscopy if eight weeks of proton pump inhibitor therapy are ineffective. In this case, there is documentation of heartburn symptoms despite longstanding proton pump inhibitor therapy. Therefore, the requested upper endoscopy is medically necessary for the evaluation of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested monitored anesthesia care. The provided records do not document reasons for the use of monitored anesthesia care supported in the medical literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, American Society of Anesthesiologist (ASA) class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures (which are performed with moderate sedation), and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. The submitted records do not support the medical necessity of monitored anesthesia care over conscious sedation in this case. Therefore, the requested monitored anesthesia care is not medically necessary for the treatment of this patient. 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 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.