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

The parent of a 12-year-old male enrollee has requested urgent care services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that this patients pain was acute in nature as it had reportedly started earlier that same day. The patients vital signs were normal and no elevated temperature was recorded. In consideration of the patients age, there are several common causes of knee pain in patients without a history of trauma, none of which are likely to require emergent or urgent treatment. In the absence of any additional symptoms, including fever or intense pain on slight movement, infection was also unlikely. Given this patients history and the physical findings on examination, although the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe the patient was at risk of serious jeopardy to his health, serious impairment to bodily function or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet the criteria for an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization (day treatment program) services provided from a specific date and forward, readmission to the partial hospitalization (day treatment program), or readmission to inpatient (residential) treatment.  Findings:  The physician reviewer found that according to the Texas Commission on Alcohol and Drug Abuse (TACADA) guidelines, continued stay at the PHP level is met for treatment of substance abuse if one of the following two criteria are met: Patient demonstrates minimal insight into the patients defeating use of alcohol/drugs, but documentation in the record indicates that the patient is progressing in treatment; or patient identifies with the severity of the alcohol/drug problem and manifests insight yet does not demonstrate behaviors that indicate that the patient is developing problem solving skills necessary to cope with the problem. This patients records indicate that the patient has made some progress, to the point that he was released to a lower level of care. However, the records also demonstrate that he still has minimal insight into his problems and has not developed good problem solving skills to cope with his addiction. Thus, TACADA criteria are met. In addition, the patients history is consistent with multiple episodes of relapse when treated at the IOP level of care. Specifically, the treatment notes on his last treatment day and date of discharge state that he is at risk for immediate relapse at the time of discharge. This high probability of immediate relapse satisfies the Milliman criteria for PHP treatment as well. For these reasons, continued treatment at the PHP level from the date requeseted and forward is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for corneal collagen cross-linking for treatment of his keratoconus. Findings:  Three physician reviewers found that the medical evidence supports the requested services in this clinical setting.  Based on the patients vision loss and documented progression, corneal collagen cross-linking is likely to be the most effective treatment available. There is medical evidence which shows corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant.  Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is no other treatment option available to slow or halt disease progression.  Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2, and 3 are board certified in ophthalmology 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: Overturned

A 36-year-old female enrollee has requested Cymbalta, 30 mg daily for treatment of her fibromyalgia and cervical disc disease with radiculopathy. Findings:  The physician reviewer found that this patient tried Neurontin and it made her drowsy. Sedation is an intolerable side effect for this patient, given her lifestyle. She reportedly had inadequate relief with gabapentin yet Cymbalta has been effective. In addition, Cymbalta is approved by the Food and Drug Administration (FDA) for treatment of fibromyalgia. Thus, Cymbalta, 30 mg is medically necessary for management of this patients medical conditions of fibromyalgia and cervical radiculitis and the denial was not appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left transtibial prosthesis for treatment of the enrollees left transfemoral amputation. Findings:  The physician reviewer found that in this case, the patients prosthesis is aged and due for replacement. The clinical notes document that the provider anticipates an increase in the patients functional level with replacement of the prosthesis and addition of a microprocessor component. In the medical literature, the authors reported that transfemoral amputees using a microprocessor-controlled knee have significant improvements in gait and balance. As this patients functional improvements are expected to be ongoing, the requested upgrade to microprocessor is justified. For these reasons, the requested left transtibial prosthesis is supported as medically necessary for treatment of this patients transfemoral amputation. Final Result: The physician 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 physician 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: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 17-year-old male who has a history of spinal stenosis, degenerative disc disease, spinal radiculopathy, and facet arthroplasty. He underwent lysis of epidural adhesions in December 2004. The Health Plan has denied reimbursement for the procedure stating it is experimental for treatment of the patients back pain.The requested procedure is not standard of care and is of unproven efficacy. There is no class I literature to support lysis of adhesions at this time. The patient was likely to receive greater benefit from standard therapies. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 17-year-old male who has a history of back pain as a result of spinal stenosis, degenerative disc disease, spinal radiculopathy and facet arthropathy. In December 2004, he underwent percutaneous lysis of adhesions. His parent is requesting reimbursement for the procedure at issue. The Health Plan has denied this request on the basis the efficacy of lysis of epidural adhesions has not been established.There is no clear evidence demonstrating the efficacy of lysis of epidural adhesions. This procedure is not the standard of care and remains investigational. Determination of its clinical worth awaits performance of blinded, controlled trials to establish true benefit. Consequently, the patient was likely to obtain superior results with standard therapy.  Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 17-year-old male who has chronic low back pain. The patient has undergone several pain management techniques including lysis of epidural adhesions. The patients parent has requested reimbursement for this procedure. The Health Plan considers the procedure at issue experimental in nature.The Health Plans denial should be upheld. This patient has chronic low back pain. Percutaneous lysis of epidural adhesions has not been proven to be effective for treatment of patients such as this patient. There have been no class I trials demonstrating the long-term efficacy of lysis of epidural adhesions for treatment of the patients condition. Accordingly, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 30-year-old male who has requested authorization for a bilateral medial thigh lift. The patient has excessive, hanging skin in the medial thigh region following a 200-pound weight loss. He reports irritation involving the overhanging skin. The patient states he must wrap the thigh in an ace wrap daily to prevent irritation and abrasions. The Health Plan has determined a bilateral thigh lift is cosmetic in nature and therefore, is not medically necessary for treatment of the patients excess skin. Based upon the submitted photographs, the patients overhang does not appear to be severe. In addition, the photographic evidence does not document a medical condition involving the medial thigh region (e.g., abrasions, irritation). In the absence of documented evidence of medial thigh irritation and abrasion there is no medical justification 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: Urgent Care
Decision: Overturned

A 28-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the enrollees presenting history, believe he or she was experiencing an emergency medical condition requiring immediate medical attention. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part.  Pain of 7/10 severity associated with a fever and visible signs of infection of the upper airway constitutes symptoms that a prudent layperson could reasonably interpret to be an emergency medical condition. The patient was also advised by a medical professional to seek emergency services. For these reasons, the patients decision to seek treatment in the Emergency Department was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient services provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had a serious addiction to alcohol which contributed to impairment across multiple functional domains.  He reported a family history and an early age of first use, both of which are associated with more severe cases of alcoholism. He had medical conditions that were impacted by his alcohol consumption.  He had strained relationships due to his drinking. He had a co-occurring psychiatric disorder and substance use disorder. He did well with intensive outpatient program services previously when treating his opioid addiction. During the disputed timeframe, the patient attended, participated and benefitted from the intensive outpatient program services. The treatment was reasonably expected to improve the patients condition and prevent a worsening episode of illness or relapse.  In sum, service delivery at the intensive outpatient program level of care was safe, appropriate and consistent with good medical practice while the duration of services aligned with community practice standards. Therefore, intensive outpatient services provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for botulinum toxin injections for treatment of the enrollees chronic pelvic pain syndrome. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Botulinum toxin bladder injection therapy is considered a safe and effective option for patients with interstitial cystitis and bladder pain syndrome. This treatment may be of particular benefit for patients with significant irritative urinary symptoms associated with bladder cycling. This patient has failed multimodal therapy. Therefore, she was an appropriate candidate for salvage therapy using Botox injections. In sum, botulinum toxin injections were likely to have been of greater benefit than other treatment options. Final Result: Two of three reviewers determined that the services at issue were 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 urology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Taltz.Findings: Chronic plaque psoriasis is a disease that affects quality of life. In recent years, biologic medications like Taltz have been shown to control disease safely for the vast majority of patients. Taltz (ixekizumab) is approved by the U.S. Food and Drug Administration for the treatment of chronic plaque psoriasis. According to the joint guidelines for the treatment of psoriasis from the American Academy of Dermatology and the National Psoriasis Foundation, ixekizumab is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. Multiple randomized controlled trials evaluating ixekizumab versus placebo establish the efficacy of this drug in patients with moderate-to-severe psoriasis. Additionally, at four weeks, the psoriasis area and severity index (PASI) score, a measure of improvement, is significantly better with ixekizumab than Enbrel. In this case, the patient is already taking Taltz and is doing well. Additionally, the patient has tried and failed Otezla. Therefore, Taltz is medically necessary for the treatment of the patients medical condition.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 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: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested for Ketamine IV therapy for treatment of her reflex sympathetic dystrophy. Findings:  Three physician reviewers found that Goldberg and colleagues conducted an open-label, prospective, pain journal evaluation of a 10-day daily infusion of intravenous Ketamine in patients with complex regional pain syndrome. They obtained statistically significant improvement in pain scores. However, there was no standardized comparison group. Similarly, Koffler and colleagues have employed a high dose of Ketamine protocol inducing a coma for five days in an intensive care setting. They also demonstrated marked improvement in pain scores. But again, there was no comparison group, making this study weak from a medical evidence point of view.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female has requested selective internal radiation therapy (SIRT) for treatment of her breast cancer.  Findings:  Two physician reviewers found that the patient has a history of left breast infiltrating ductal carcinoma. At the time of her original diagnosis five years ago, she underwent mastectomy with chemotherapy. Her chemotherapy included agents Abraxane, Xeloda, and Navalbine.  Despite this treatment, the patient has developed extensive hepatic disease including multiple confluent metastatic foci causing enlargement of her liver. A computed tomography (CT) scan performed one year ago and subsequent positron emission tomography/computed tomography (PET/CT) both confirmed the presence of this extensive disease. The patient also reportedly has skeletal metastases but is currently experiencing her primary symptomatology from the bulky liver disease. The patient and her provider are seeking authorization and coverage for selective internal radiation therapy (SIRT) therapy in order to palliate the symptoms and preserve liver function. This patient has undergone conventional chemotherapeutic agents without control of the severe bulky metastatic liver disease as demonstrated on imaging studies. At this juncture, the goal of treatment is debulking of the liver disease which can both improve the patients symptoms and help preserve liver function. As demonstrated by Bangash and colleagues in the clinical studies on SIRT: Radioembolization with 90Y brachytherapy device may be a viable therapeutic option for the treatment of breast cancer liver metastases in patients who have progressed or failed on standard of care polychemotherapy. As SIRT for breast carcinoma has been shown to be efficacious and has demonstrated acceptable safety profile, SIRT is indicated for management of this patients medical condition as likely to be more beneficial than any available alternative therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. The medical evidence supports hyaluronic acid injections in the knee as a possible option for patients with severe 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. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome, or osteochondritis dissecans. The peer-reviewed literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee, but states that application in sports-related chondropathy has yet to be fully assessed. The ideal indication in the knee appears to be moderate femorotibial osteoarthritis without swelling. This patient presents with bilateral anterior knee pain, left greater than right, with popping and clicking in the left knee. Her symptoms are worse with colder weather, climbing ladders, climbing hills, going up/down stairs, and with heavy lifting. Clinical examination findings have been consistent with imaging evidence of patellofemoral chondromalacia and degenerative joint disease. Current evidence-based medical guidelines and literature do not support the use of Euflexxa injections in the treatment of patellofemoral osteoarthritis. The current evidence does not support the requested services in this clinical setting. Therefore, the requested Euflexxa injections 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 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.