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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for occupational therapy. Medical literature notes that occupational therapy services may be indicated in the management of children with autism spectrum disorder (ASD) to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. The authors further note that two-thirds of preschool-aged children with ASD are reported to receive occupational therapy services. In this case, the patient was receiving weekly occupational therapy and occupational therapy notes reported that the patient was making progress toward therapy goals. While an occupational therapy evaluation reported that the patient did not participate in adult led tasks, in an undated letter, the patients mother reported that the patient tended to shut down and become uncooperative in unfamiliar situations due to sensory overload. In this case, given that an assessment by an unfamiliar therapist may be inadequate to ascertain the patient's potential to benefit for occupational therapy, and as the records documented that the patient was making progress toward her therapy goals, the requested services are medically indicated. Therefore, occupational therapy is medically necessary for the treatment of this patient.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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Facial Feminization Surgeries (FFS).The World Professional Association for Transgender Health (WPATH) has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. The WPATH has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition (WPATH 2016). Furthermore, Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life (Ainsworth and Spiegel, 2010).In this case, the patient has submitted multiple documents that support her claim that the requested facial feminization surgeries are medically necessary. A letter from the patients therapist states that the requested facial feminization surgeries will serve to improve the patients personal safety and mental health-related quality of life. The patients primary care provider also supports the medical necessity of the requested surgeries to treat the patients gender dysphoria. Under these circumstances, the requested Facial Feminization Surgeries (FFS) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Actemra solution prefilled syringe 162 mg/0.9 mL. The American College of Rheumatology guidelines for the treatment of rheumatoid arthritis recommend that patients who do not tolerate monotherapy with methotrexate try a tumor necrosis factor (TNF) inhibitor or any other non-TNF inhibitor biologic. Buckland reports that a phase IV study in patients with severe rheumatoid arthritis receiving tocilizumab (brand name Actemra) or adalimumab as monotherapy, without concomitant methotrexate, demonstrated that tocilizumab was superior to adalimumab for reducing the severity of disease in this setting. Given that current medical literature supports the efficacy and safety of Actemra in this clinical setting, the requested medications is medically indicated. Therefore, Actemra solution prefilled syringe 162 mg/0.9 mL is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The 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:  An enrollee has requested Otezla for treatment of his psoriasis. The physician reviewer found that the request for Otezla is not medically necessary in this clinical setting. The patient is requesting coverage for Otezla (apremilast) for treatment of psoriasis affecting greater than 30% body surface area. This patient is an appropriate candidate for systemic therapy to control his chronic plaque psoriasis. However, there are several options available including injectable biologic such as etanercept or adalimumab. It would be medically appropriate and safe for the patient to try one of the injectable medications to treat his disease.  In addition, there is a lack of documentation demonstrating contraindications or intolerance to other medications such as etanercept or adalimumab. Given that the patient has not failed other systemic therapies, the request for coverage of Otezla is not 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 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: Overturned

A 57-year-old male enrollee has requested rhinophyma surgery for treatment of his rosacea and rhinophyma. Findings:  The physician reviewer found that this patients condition constitutes an abnormal structure of the body, as consistent with the California Reconstruction Statute. Rhinophyma is a condition of the nose where there is sebaceous gland hyperplasia causing the nose to become bulbous and lobulated. It is also characterized by fibrosis, follicular plugging and teleangiectasis. It is categorized as a glandular form of acne rosacea. The actual cause is unknown but can be considered an overgrowth of tissue, thus acting like a tumor. Some providers, as reported by Thorne and colleagues, indicate that it may also be considered a disease. The authors state that, Understanding the disease and controlling the underlying process with an optimal dermatologic regimen are critical. This patients records demonstrate that he has undergone different topical regimens without success. Thus, the patient has already been treated by dermatologic means. Overall, it appears the primary goal of the procedure is to address non-cosmetic issues. Moreover, an appropriate procedure would have an excisional nature that allows for pathologic analysis. As such, the requested surgery should be determined to be reconstructive in nature and is therefore medically indicated.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for parent child interactive therapy (PCIT) as a psychiatric emergency medical services.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric 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. Based on the documentation submitted for review, the patient did not receive emergency medical services during the dates of service at issue. In this case, the PCIT services were not emergency medical services as the medical records do not show that an emergency existed. There was no evidence that a recommendation to an emergency room, crisis center, or a mobile crisis service was made or occurred due to a potential psychiatric emergency. There is no documentation suggested this patient was out of control, or had impulsivity that was not typical for his age. Moreover, there is no evidence of suicidal or homicidal ideation, and no evidence of any psychosis. There is no evidence that the patient exhibited any self-injurious behavior or harmful behavior towards others.  Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for speech therapy. The speech therapy services provided were and are medically necessary for treatment of the patients medical condition. The patient has autism spectrum disorder with severe expressive and receptive language delays. He would be unable to state his name and address if lost, which poses a safety issue. Speech therapy is indicated to address his oral motor apraxia, which is impairing his expressive language. His condition is severe enough to result in inadequate oral intake of food and fluids, necessitating gastrostomy tube placement. This type of speech therapy is not provided in a school setting, where the emphasis is on speech for educational purposes. Colleagues emphasized the importance of the inclusion of speech therapy in the overall management of children weaning from tube feeding to oral feeding. Colleagues discussed the difference between the speech therapy typically provided in school, compared with that provided by a speech therapist who is an expert with augmentative and alternative communication (AAC) devices. The authors state that interventions provided to the children by general speech-language pathologists (who were not AAC experts) tended to be broader in scope, focusing on reducing underlying impairments. This patient is noted to have an AAC device. The authors found that interventions provided by AAC experts tended to focus on improving activities and participation and were oriented toward improving functional communication. As this patient does not have functional communication skills, the speech therapy services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 pediatrics and 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

The parent of an eight-year-old male with a history of escalating disruptive, defiant behavior is requesting authorization of inpatient psychiatric treatment services.Reviewers Findings:  The reviewing physician found that there is no objective evidence that the patient required inpatient psychiatric treatment services.  The Health Plan denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female has requested coverage for past pregnancy screening and diagnostic testing for evaluation of her pregnancy.   Findings:  Three physician reviewers found that the patient is pregnant with her first pregnancy achieved with in vitro fertilization (IVF). The records indicate that the donor egg is from a 22-year-old without any known personal or family history of significance. The patient was referred by her provider for genetic counseling to discuss screening and diagnostic testing options. The patient was offered various testing including first trimester screening, amniocentesis, and non-invasive prenatal testing. Following discussions with the genetic counselor, the patient was evaluated with cell-free DNA testing. The American College of Obstetricians and Gynecologists (ACOG) guidelines show there is a lack of outcome data supporting cell-free DNA testing in low risk patients. Non-invasive prenatal testing that uses cell-free DNA may be indicated for evaluation following pretest counseling in well selected patients. However, this type of testing is not supported for routine laboratory assessment. In addition, cell-free DNA testing does not replace the precision obtained with standard diagnostic tests such as ultrasound or amniocentesis. Currently, this testing is not supported as likely to be more beneficial than any available conventional therapy in evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested acupuncture for treatment of her back pain. Findings:  The physician reviewer found that low back pain generally tends to improve naturally with time but can also recur intermittently or become more severe or chronic in nature. With regard to treatment, there is insufficient high-grade, objective evidence that acupuncture causally improves health or functional outcomes in the setting of chronic low back pain. Specifically, there is no reliable and reproducible scientifically-based medical literature that supports the efficacy of acupuncture in this clinical setting. A recent review from Lewis and Abdi noted that, Most of the published articles about acupuncture in the biomedical literature consist of case reports, case series, or intervention studies with designs inadequate to assess its efficacy. Thus, it is imperative that further research be performed, both preclinical to help elucidate the mechanisms underlying acupuncture, and clinical to justify its clinical application. The authors concluded that, There is a paucity of high-quality research assessing efficacy of acupuncture in the management of [low back pain]. As such, the requested acupuncture therapy is not of proven efficacy for this condition and therefore not medically necessary in the management of this patients low back pain.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested residential recovery treatment for treatment of her heroin dependence and amphetamine dependence. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has struggled with a formidable addictive illness, and aggressive patient-centered care is indicated to achieve the desired end state of sustained sobriety and optimal functionality.  However, the patient demonstrates no evidence of a psychiatric syndrome that would require treatment in a 24-hour supervised setting.  Per the American Society of Addiction Medicine, a thorough and current assessment culminates with the determination of the proper placement setting.  In this patients case, an updated comprehensive assessment is needed to support the requested services.  All told, residential recovery treatment is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Proton Beam Radiation Therapy for newly diagnosed moderately differentiated adenocarcinoma of the gastroesophageal junction. History included reflux esophagitis and Barretts esophagus. The enrollee indicated being in good health until he noticed having difficulty eating, with a sensation of food getting stuck, leading to substantial weight loss.  PET/CT showed no metastatic disease and a mass in the distal esophagus. Medical oncology recommended treatment including concurrent chemotherapy with radiotherapy, followed by surgical resection. The enrollee presented to Radiation Oncology regarding the role of proton therapy in the treatment of his cancer. After discussion, the patient opted for the proton beam radiation therapy. Three of three reviewers indicated that the medical literature does not support this treatment as a Group 1 or highly recommended treatment for esophageal cancer. The literature indicates proton beam is appropriate in clinical settings where reduction in dose to organs, such as heart and lungs is required.  Based on the medical documentation, that is not an issue in this case and there is no evidence supporting a meaningful difference in the clinical outcome with proton beam radiation therapy. The data supporting the use of proton beam radiation therapy in this setting are early and evolving and treatment under this circumstance should be as part of a clinical trial.  Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified in Radiation Oncology and are actively practicing.  All three 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty.Findings:  Three physician reviewers found the scientific evidence and peer-reviewed literature support improvement in health outcomes with the use of bronchial thermoplasty. Bronchial thermoplasty has been recommended for the treatment of severe persistent asthma. The literature supports the safety and efficacy of this modality. This patient has limited options, and he continues to utilize his rescue inhaler three to four times per day and utilizes steroids with exacerbations. Therefore, the requested bronchial thermoplasty is likely to be more efficacious than other available treatment options. 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease 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: The patient has requested reimbursement for office visit, transvaginal ultrasound, and/or the pelvic non-obstetrical ultrasound. The records provided for review support a diagnosis of female infertility. The patients treatment plan included ovulation induction with letrozole followed by intrauterine insemination with donor sperm. This treatment plan is consistent with the recommendations from the American College of Obstetricians and Gynecologists (ACOG). The patient was treated with services such as the administration of letrozole, close clinical follow-up with office visits, and ultrasound to evaluate follicular maturation. As noted in the ACOG recommendations, the close clinical follow-up with office visits, pelvic non-obstetrical ultrasound, and transvaginal ultrasound were appropriate to treat this patients infertility. The medical literature also supports use of letrozole in the treatment of female patients with infertility (Legro, et al.). All told, the office visit, transvaginal ultrasound, and the pelvic non-obstetrical ultrasound were medically necessary for 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 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.