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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested finasteride, estradiol valerate and spironolactone for treatment of her gender dysphoria. Findings:  The physician reviewer found that review of the submitted clinical documentation support the medical necessity of the requested medications. The requested dosages of finasteride, estradiol valerate and spironolactone are consistent with Endocrine Society guidelines for the treatment of transgender females. Estrogen (estradiol valerate) can be given orally, transdermally or parenterally (IM). Each has its risks and benefits. Measurement of serum estradiol levels is used to monitor estrogen therapy in all forms. The requested estradiol valerate is reasonable and consistent with Endocrine Society Guidelines for the treatment of transgender females. As such, the requested dosage of estradiol valerate is medically necessary for this patient. Spironolactone is an antihypertensive agent but also directly inhibits testosterone secretion and androgen binding to the androgen receptor. Thus, it is an effective anti-androgen and allows estrogen to have its fullest effect. The requested spironolactone is clinically appropriate and medically necessary in the patients care. Finasteride (a 5-alpha reductase inhibitor) blocks the conversion of testosterone to the more active agent, 5-alpha-dihydrotestosterone. These medications have beneficial effects on scalp hair loss, body hair growth, sebaceous glands and skin consistency. As such, the requested dose of finasteride is medically appropriate and necessary in this case.   Final Result: The reviewer determined that the requested medications 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 endocrinology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Wide local excision of melanoma in situ.  Per Health and Safety Code section 1345(h), health plans are required to cover urgent care services. Per that same provision, urgent care services are defined as, services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury. The records provided for review document that this patient presented to his provider with a diagnosis of melanoma in situ on the cheek, which required excision. Based on the definition of urgent care services, the patients melanoma did not require urgent excision on the date of service. The American Academy of Dermatology (AAD) guidelines on the management of melanoma recommend definitive excision within two months of diagnosis. Moreover, current data suggest that there is a paucity of evidence to suggest that a shorter timeline for removal of the tumor changes long-term patient health outcomes. Based on these findings, the procedure could have been performed within the two-month timeframe without urgent excision on the date of service. A wide local excision by a plastic surgeon or dermatologist was reasonable. There was no reasonable expectation of deterioration in the patients health to support an urgent indication for the procedure. Therefore, the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. 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

The patient has requested authorization and coverage for excimer laser therapy (30 sessions). The patient has been diagnosed with vitiligo. The patient was noted to respond well to prior excimer laser therapy. Researchers noted that a 308nm excimer laser (EL) has been widely used to treat patients with localized vitiligo. EL treatment would not increase the risks of premalignant skin lesions and skin cancers in patients with vitiligo. Based on our results, EL is likely to be a safe treatment option for patients with localized vitiligo. In this case, the patient was noted to respond well to prior excimer laser therapy. The medical evidence supports the requested services in this clinical setting. Therefore, excimer laser therapy (30 sessions) 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that the requested residential treatment was medically necessary for treatment of the patients medical condition.  Based on the documentation provided, the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  Further, in reviewing the clinical documentation, the residential treatment provided thereafter was safe, appropriate and consistent with good medical practice. The duration of services for a case of this complexity was consistent with community standards. Finally, the entire course of care was reasonably expected to improve her condition and prevent a more serious episode of illness. Accordingly, the services at issue were medically necessary for treatment of the patients behavioral health condition.   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: Medical Necessity
Decision: Overturned

The patient is a 34-year-old female who is requesting authorization for the medication Provigil for shift work disorder. The patient indicates she has trouble sleeping due to her random work schedule. Further, excess daytime sleepiness is evidenced by the patient inappropriately falling asleep during regular working hours as well as while driving. The patient has received a trial of Provigil with good results. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients medical condition.The clinical findings of a patient falling asleep during working hours and while driving are sufficient to confirm excessive sleepiness. Based upon the evidence provided, it appears the cause in this case is due to the patients random work schedule. Excessive drowsiness resulting from shift work sleep disorder is an indication for Provigil. Though the patient has not undergone a polysomnography, formal sleep studies are rarely indicated in the initial evaluation of insomnia. Insomnia is primarily a clinical diagnosis, and the American Sleep Disorders Association Standards of Practice Committee Guidelines do not suggest polysomnography for the routine evaluation. The patients provider has provided the patient with a clinical trial of Provigil, and from all indications the medication has been effective in reducing the patients excessive sleepiness. Further, there is no clear clinical evidence of an alternative diagnosis. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. Consistent with this support, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an extra wide hospital bed (E0303). Hagen reports that along with motor and sensory deficits, instabilities of the cardiovascular, thermoregulatory and broncho-pulmonary system are common after a spinal cord injury. Sezer and colleagues report that the goals of rehabilitation and other treatment approaches in spinal cord injury are to improve functional level, decrease secondary morbidity and enhance health-related quality of life. This may include the use of durable medical equipment such as wheelchairs or hospital beds to enhance mobility that has been lost due to the spinal cord injury. In this case, the patient has a documented height of 64 inches, and a weight of 180 pounds. Given that the submitted records did not document reasons why the patient could not stretch in a regular sized bed, or an evaluation from physical or occupational therapy with findings that an extra wide hospital bed is recommended for this patient, the requested equipment is not medically indicated. Therefore, the requested extra wide hospital bed (E0303) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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

The parent of a 16-year-old male enrollee has requested inpatient services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patient has multiple risk factors for suicide, including his current diagnoses of bipolar disorder and substance abuse and chronic, intermittent suicidal ideation. Further, his suicide attempt occurred just after discharge from a previous hospitalization. He presents with a history of violence and impulsivity, which are exacerbated by his current non-compliance with medication and apparent lack of insight regarding his substance use behavior. This patients previous suicide attempt occurred at home with family members in the house and he has a turbulent relationship with his mother. In addition, the patient has verbalized his intention to see his friends (who are also substance abusers) while at home. Perhaps because of the patients non-compliance with medication, his mental status examinations in the hospital would suggest a possible escalating hypomanic/manic state. This would further impair the patients already questionable judgment, and render him prone to impulsivity. Applying the American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists placement criteria in this case, the risk of monitoring such an unstable patient outside of a structured, 24-hour facility is not medically sound. A partial hospital setting would also be inadequate to maintain the safety of such a patient at this time. As such, I have concluded that the inpatient services at issue were and are medically necessary from the said dates onward.
Appeal type: Medical Necessity
Decision: Upheld

Forty-three year-old female with Mediastinal lymphadenopathy is requesting PET Scan for further evaluation.  The patient had CT scans of the chest and abdomen for left upper quadrant pain in March 2006. Mediastinal lymphadenopathy was identified. The patient is presently asymptomatic except for occasional night sweats. There is a past history of hypothyroidism, prediabetes and adrenal insufficiency.Reviewers Findings:Neither a positive nor a negative PET scan would add to the evaluation of the patients adenopathy. Adenopathy without a specific etiology is not an approved indication for PET scan under the guidelines of the Centers for Medicare and Medicaid Services.  If a specific diagnosis is needed, then biopsy should be considered with mediastinoscopy. Follow up CT scans can also show the stability of the adenopathy.  Therefore, the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee requested authorization and coverage of skilled nursing facility (SNF) services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees orthopedic injuries.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clonazepam 0.5 mg. Medical literature notes that benzodiazepines with an intermediate to long onset of action such as clonazepam might have less potential for abuse and less risk of rebound and thus helpful for chronic management of GAD. One study reported that clonazepam can be successfully discontinued without any major withdrawal symptoms if the dose is reduced gradually. The study focused on patients who have been treated with clonazepam for at least three years. This patient has been on the medication for many years. Thus, she requires a slow taper and sudden discontinuation of the medication is not recommended without a plan to taper and/or an alternative medication. The requested treatment is appropriate to treat the patients condition and sudden discontinuation could cause serious side effects. All told, clonazepam 0.5 mg is medically necessary for 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 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

A 49-year-old female enrollee has requested a Lap-Band procedure for treatment of her obesity.  Findings:  The physician reviewer found that the National Institutes of Health (NIH) guidelines indicate that adjustable gastric banding (AGB) procedures, such as the Lap-Band, work primarily by decreasing food intake. The surgery involves placement of a small bracelet-like band around the top of the stomach to produce a small pouch about the size of a thumb. The outlet size is controlled by a circular balloon inside the band that can be inflated or deflated with saline solution to meet the needs of the patient. The NIH criteria for patients with a BMI under 40 suggest that a serious obesity-related health problem exist in order for the procedure to be medically indicated. This patient has a BMI of 38 with well documented knee injuries and associated weight-bearing concerns in addition to Obstructive Sleep Apnia. The loss of weight for this patient is likely to provide substantial benefit for her comorbid conditions and is consistent with the NIH recommendations. She has already failed numerous diets and treatment with Meridia and Xenical. Additionally, the provider reports that the patient has no contraindications for the requested procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam therapy for treatment of the enrollees left breast cancer. Findings: The physician reviewer found that proton therapy has a specific indication in young adult patients in this clinical setting to help reduce cardiac and normal tissue exposure. Young adults are particularly sensitive to secondary malignancy risks. For this patient, there is concern of the contralateral breast, thyroid, and lung, for which proton therapy can provide a clinically meaningful reduction in anticipated risks. Young adults are also particularly sensitive to late cardiac injury, which is another compelling reason to consider proton therapy in this patient. Reviewing the isodose lines in this patients treatment plan supports proton therapy as the target is concave around the chest wall, and there is additional dose being delivered to the retropectoral nodes. Given this support, the requested proton therapy is medically necessary for treatment of this patients left-sided breast cancer.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg-100 mg, one tablet daily for 12 weeks for treatment of the enrollees 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Norco. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The authors further note, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic back pain related to a past nephrectomy procedure. The records noted that the patient was taking Norco and Ambien concurrently, and that the treating provider expressed concerns about the increased risk of respiratory depression due to this combination. In this case, the treatment provider determined that the risks outweighed the potential benefits and requested that the patient select to continue either Norco or Ambien to avoid the risks associated with combined use. However, the patient declined to discontinue one of the medications. The patient has been referred to pain management for a trial of alternative treatment modalities. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, Norco is not medically necessary for the treatment of this patient.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.