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

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement and prospective authorization and coverage for intensive physical therapy, occupational therapy, speech therapy, recreational therapy and all medications associated with current conditions.  Findings:  The physician reviewer found that functional impairments due to traumatically acquired brain insults improve with time, i.e., natural recovery processes.  These impairments are also amenable to rehabilitation interventions.  Nevertheless, deficits can remain severe, particularly in the setting of severe injuries.  A protracted period of functional dependency following intracerebral hemorrhage in particular can be high.  In this case, the patient sustained a severe traumatic brain injury.  He has made significant progress in multiple domains over a period of time, but continues to have significant deficits in cognition and carryover.  He continues to have ongoing rehabilitative needs, but these can be met at a less intensive setting of care than acute inpatient rehabilitation.  His course and outcomes are not expected to be marginally improved with a higher intensity of rehabilitative services at this time.  His prognosis for full functional recovery remains guarded on account of his underlying injuries.  He remains at risk for health-related complications regardless of care setting.  Notably, his treating providers have not recommended ongoing acute inpatient rehabilitation.  Further rehabilitative services are necessary going forward, but these services can be provided in a skilled nursing facility level of care.  There are otherwise no documented ongoing needs requiring ongoing care at the acute inpatient rehabilitation level with close physician supervision, specialized rehabilitation nursing services and intense multidisciplinary therapy services.  The acute inpatient rehabilitation in question is not medically necessary for this patient based on the available records.  Thus, intensive physical therapy, occupational therapy, speech therapy, recreational therapy and all medications associated with current conditions from date of dispute onward were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility (SNF) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who is status post left hip revision surgery. The submitted documentation supports the medical necessity of the services at issue. Researchers indicated that more therapy hours in SNFs improve outcomes. The patient had not met the occupational therapy and physical therapy goals as set forth at the time of initial evaluation. Occupational therapy noted indicated that the patient had met long-term goals for dressing and toileting and physical therapy notes indicated that goals for ambulation and bed mobility were not met until later.  The patient was receiving skilled physical therapy services and advancing toward rehabilitation goals in preparation for discharge to home.  These skilled therapy services are not consistent with custodial care. Therefore, the SNF services provided were  medically necessary.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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing. Therapy for certain adenocarcinomas is affected by the finding of EGFR mutations. All patients with EGFR mutant lung cancers eventually develop acquired resistance to EGFR tyrosine kinase inhibitors (TKI). Studies identified the EGFR T790M mutation as the most common mechanism of acquired resistance, conferring resistance to erlotinib in 60% of patients with progressive disease on erlotinib. While a TKI, osimertinib, is available to target this mutation, the mutation must first be identified. In this case, the Guardant360 test, a liquid biopsy, was used to determine whether the patient had developed an EGFR T790M mutation while results of a bronchoscopy were pending. Based on the available data and the clinical circumstances of this patient, the Guardant360 test was appropriate and consistent with the NCCN guidelines. Therefore, the Guardant360 testing at issue was likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the Guardant360 testing at issue was likely to be 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 be 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 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: Medical Necessity
Decision: Upheld

The father of a four-year-old male enrollee requested authorization and coverage of physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees Rubinstein-Taybi syndrome.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: Upheld

A 37-year-old female enrollee requested authorization and coverage of IVIG therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy.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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg tablets for treatment of the enrollees arthropathic psoriasis. Findings:  The physician reviewer found that the request for Otezla 30 mg tablets is not medically necessary for treatment of the patients medical condition. The medical records submitted for review fail to demonstrate that the patient has had a trial and failure of methotrexate and tumor necrosis factor (TNF) inhibitors such as Enbrel and Humira. Based on the clinical records submitted for review, the request for Otezla 30 mg tablets has not been established as medically necessary for treatment of the patients medical condition. 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 sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for HALO ablation treatments. Findings:  The physician reviewer found that  current medical literature and guidelines support the use of radiofrequency ablation in Barretts esophagus with high-grade dysplasia and especially with low-grade dysplasia, confirmation of the presence of dysplasia by a second pathologist, or panel of pathologists is recommended. The American College of Gastroenterology (ACG) notes, Current evidence supports the importance of having all readings of dysplasia confirmed by a second pathologist with extensive experience in the interpretation of Barretts associated neoplasia. The ACG notes that diagnoses of both high-grade and low-grade dysplasia should first be confirmed by a second pathologist with expertise in gastrointestinal pathology and in Barretts esophagus. Belghazi and colleagues report that in cases of low-grade dysplasia confirmed by an expert pathologist, prophylactic ablation using radiofrequency ablation of the Barrett's segment has proven to significantly reduce risk of neoplastic progression. Regarding endoscopic eradication therapy for patients with Barretts esophagus-associated dysplasia and intramucosal cancer, the Standards of Practice Committee guidelines recommend continued surveillance biopsies even after ablation, as buried glands may persist and become dysplastic or neoplastic.  In this clinical setting, given that the records did not demonstrate a diagnosis of low-grade dysplasia established and confirmed by more than one pathologist, the services at issue were not medically necessary. Therefore, HALO ablation treatments were and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 63-year-old female enrollee has requested authorization and coverage for a third series of hyaluronic acid injections (Euflexxa) to the left knee.  Findings:  The physician reviewer found that the issue in this case is whether the Euflexxa injections (viscosupplementation) are medically necessary for the treatment of this patients condition. Viscosupplementation is an accepted treatment for osteoarthritis of the knee in appropriate patients (Bellamy, et al.). It is most suitable for patients with mild to moderate involvement, for whom other approaches are contraindicated, or have failed (Dagenais). A single retreatment is generally considered appropriate in patients with documented clinical improvement from the initial course of treatment, after six months have elapsed (Waddell and Bricker). In this case, the patient had one series of injections into the left knee by the rheumatologist and another series of injections into the right knee by her orthopedic surgeon more than a year later. Thus, neither knee had a second series of injections, and the prescribed series would therefore be the second series for the left knee. Thus, the requested Euflexxa injections are medically necessary and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) referral to a licensed midwife (not a certified nurse-midwife) for prenatal and postnatal care and (2) referral to an International Board Certified Lactation Consultant (IBCLC) for prenatal and postnatal care. There is a lack of clinical documentation in the submitted records supporting referral to a licensed midwife, given that certified nurse-midwives are licensed by the California Board of Registered Nursing as an advanced practice provider and have been made available to the patient. Therefore, (1) referral to a licensed midwife (not a certified nurse-midwife) for prenatal and postnatal care is not medically necessary for the treatment of this patient. Researchers notes that for patients who choose to breastfeed with risk factors for breastfeeding problems or low milk supply, prenatal consultation with a lactation consultant, and special education and attention during initiation of breastfeeding may be beneficial. Therefore, (2) referral to an IBCLC for prenatal and postnatal care is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are 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 obstetrics and gynecology 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 representative of a 20-year-old male enrollee has requested for care for treatment of the enrollees parent-child relational problem, bereavement and conduct disorder, adolescent-onset type. Findings:  The physician reviewer found that the submitted documentation does not demonstrate that the patient required the intensity of services of the disputed level of care at any time during his stay. Furthermore, a GAF of 60 was listed. A GAF of 60 indicates moderate functional impairment, not severe impairment. Nor is there is no evidence of comorbid psychological or medical issues that would have warranted the level of care provided.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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 treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a consultation with a podiatrist. The submitted documentation does not support that the requested service is medically necessary. According to Fields and colleagues, foot pain is commonly reported in adult patients. A correct diagnosis is made through the patient history, physical examination of the foot and ankle, as well as imaging studies. The history of the patients pain, in this case, is not well documented. There is no documentation of an initial history of the presenting complaint or of any physical examination documenting the location of pain. There is no documentation of any acute red flag findings. There is no documentation of a response to a trial of conservative care (e.g. non-steroidal anti-inflammatory drugs, heel support, and a home exercise program). Under these circumstances, the requested consultation with a podiatrist is not medically necessary for the treatment of the patient's medical condition.Final Result: The reviewer determined that the requested service 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 family 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

The patient is a 48-year-old female who apparently has a seizure disorder and another neurological syndrome known as stiff persons syndrome. The patient has been treated with intravenous immunoglobulin (IVIG) therapy and has reported some improvement in her condition. She wishes to continue to be treated with IVIG therapy. The Health Plan has denied coverage for IVIG on the basis that it is not medically necessary for treatment of the patients condition.Stiff persons syndrome is a very rare neurological condition that can be treated in several ways. In the case of this patient it does not appear the diagnosis of stiff persons syndrome has been firmly established. The patient requires further workup to establish the diagnosis clinically and by the presence of elevated anti-GAD titres. If the diagnosis of stiff persons syndrome is confirmed, available treatments include plasmapheresis, a variety of pharmacological agents, and IVIG therapy. At this time there is insufficient evidence that the patient does in fact have stiff persons disease and has failed other available treatments for the condition. However, if the diagnosis of stiff persons disease is confirmed and there is documented evidence that plasmapheresis or pharmacological agents are ineffective for this patient or cause untoward side effects, then the patients request for IVIG therapy should be reconsidered.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a surgical consultation for gender reassignment surgery for treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that the patient has been transitioning to the male gender. The patient appears to have benefited from this transition, although he is noted to have severe dysphoria.  His provider has recommended surgical consultation. The proposed consultation is considered medically necessary as the next step in the treatment of this patients gender dysphoria. The surgical concept of female-to-male reassignment surgery is well established within the community of plastic surgeons as demonstrated in the references cited above. Each patient must be reviewed on a case-by-case basis to determine medical necessity.  In this patients case, medical necessity for the requested consultation has been sufficiently established by the submitted medical documentation, as the patient has identified as male and has already taken both reversible and irreversible steps toward his transition.  His diagnosis of gender dysphoria has affected his function psychologically and his initial surgical transition has already been noted to have provided some functional benefit. The patient has a functional deficit related to his gender dysphoria and the appropriate next step is further consultation to consider treatment options. As such, the proposed surgical consultation is medically necessary for treatment of the patients gender dysphoria. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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 for epidural injections for treatment of the enrollees low back pain. Findings:  The physician reviewer found that there is support in the medical literature as well as in the documentation for the requested services in this clinical setting. Epidural injections appropriate when patients have persistent radicular pain that has not been responsive to conservative care for at least six weeks; the patient has stable medical condition; the previous epidural was successful; and it has been more than seven days since the last epidural with a maximum of four injections in 12 months. In this patients case, the patient has radicular pain. The records show nerve impingement that corresponds to this patients symptoms. The documentation also indicates that this patient has not responded to at least six weeks of conservative care with no unstable medical conditions noted. The patient has reported that his radicular pain interferes with activities of daily living and previous epidural was successful. Furthermore, the patient is doing physical therapy regularly. 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 anesthesiology and pain 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.