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

A 31-year-old male enrollee has requested urgent care services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson would have sought immediate medical attention? Under Health and Safety Code 1317.1, `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 patient's health in serious jeopardy. (2) Serious impairment to bodily functions. (3) Serious dysfunction of any bodily organ or part.  Under 28 CCR 1300.67, `Urgently needed services` are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan's service area. Review of the submitted documentation indicates that the patient attempted to see his new primary care physician but was told that the first available appointment was two weeks later.  Waiting until that date to be seen would have constituted a delay in diagnosis/treatment of two weeks. This patients condition had been ongoing for approximately a week and a half with a low pain level and thus was not an emergent problem. However, it did present an urgent problem, as his pain was not improving and could have been indicative of a serious underlying condition that needed to be addressed. Thus, a prudent layperson would believe that he was experiencing an urgent medical condition and needed to be seen earlier than the next available appointment in two weeks.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for neuropsychological testing (Wechsler Preschool and Primary Scale of IntelligenceFourth Edition (WPPSI-IV), Vineland Adaptive Behavior Scales, Second Edition (VinelandII) and NEPSY-Second Edition). Findings:  The physician reviewer found that there is support for a portion of the requested services in this clinical setting. Specifically, the Wechsler Preschool and Primary Scale of IntelligenceFourth Edition (WPPSI-IV) and Vineland Adaptive Behavior Scales, Second Edition (VinelandII) are medically appropriate in this clinical setting.  Both these assessment tools would provide more information as to the patients cognitive skills, ultimate prognosis, social skills and motor-adaptive problem solving skills. However, there is a lack of evidence-based literature and research to support NEPSY-Second Edition as a neuropsychological assessment tool for the evaluation of this patient. There is some literature to support its use for children with very complex brain injury or those children diagnosed with cancer and in those limited cases, it was performed with children older than three years of age.  The American Academy of Pediatrics (AAP) identify three major diagnostic challenges in the comprehensive assessment of a child with a suspected ASD: determining the childs overall level of functioning; making the categorical diagnosis of an ASD; and determining the extent of the search for an associated etiology. Per the AAP guidelines, the important part of the comprehensive evaluation for this patients case is the developmental and/or psychometric evaluation.  In this patients case, a DAYC has been performed by the school but this evaluation is only a screening test. It is not a psychometric evaluation. So, in this patients case a psychometric evaluation is medically indicated. Final Result: The reviewer determined that a portion of the requested services is medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics 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 transgender female with a history of gender dysphoria. The records indicate that she has been living as female and had been on hormone therapy. She had laser therapy to decrease facial hair. Her anxiety and depression have improved since she started presenting as female. The patient has a documented history of gender dysphoria and has been on cross-gender hormone therapy. Facial feminization surgery (FFS) would enhance this patients psychological and social functioning and alleviate distress due to gender dysphoria. Moreover, the requested FFS is consistent with the World Professional Association for Transgender Health (WPATH), which states that in addition to hormonal balancing, medically necessary gender affirming or confirming surgical procedures may include certain facial plastic reconstruction as appropriate to the patient. According to WPATH, the medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. Based on the documented history of gender dysphoria, the requested FFS (forehead, brow, and nose) are medically necessary for 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 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 magnetic resonance imaging (MRI) (CPT 77046) of the right breast. Findings:  The physician reviewer found that Evaluation of the chest area after bilateral mastectomy and reconstruction is challenging. Mammogram is not recommended in the absence of breast tissue. Ultrasound has not been demonstrated to be as comprehensive or useful as MRI in this clinical setting. Post-mastectomy MRI in the setting of reconstruction has been shown to be the most effective modality for the detection of recurrent cancer, as well as other issues. In this patients case, the MRI was helpful to assist the provider in deciding whether a biopsy should be done, and if so, the location to biopsy. All told, the MRI (CPT 77046) of right breast was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the MRI (CPT 77046) of right breast was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right knee. The American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain notes that imaging assessment begins with conventional radiography, and if these demonstrate degenerative changes, MRI without contrast may be the next appropriate imaging study. In this case, the patient has a prior ACL reconstruction and symptoms of instability that were not explained by the radiographic findings. An MRI is medically indicated to evaluate for possible ligamentous or meniscus injury, and to evaluate the integrity of the ACL reconstruction. Therefore, MRI of the right knee is medically necessary for the evaluation of this patient. 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 diagnostic radiology 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 authorization and coverage for Intracept procedure at L5-S1. This patient presents with a history of chronic low back pain that has failed to improve despite treatment with physical therapy, epidural injections, sacroiliac joint injection, and facet injections. The patients provider has recommended treatment with the Intracept procedure. Highlighted in the current peer-reviewed medical literature are studies demonstrating superior health outcomes with use of the Intracept procedure as compared to standard available therapies in the treatment of patients with chronic low back pain. Researchers assessed the efficacy of intraosseous radiofrequency ablation of the basivertebral nerve in the management of patients with chronic low back pain. The authors concluded that minimally invasive radiofrequency ablation of the basivertebral nerve demonstrated a significant improvement in pain and function in patients with chronic vertebrogenic-related low back pain. Similarly, researchers reported that patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain showed sustained clinical benefits and maintained high responder rates at two years following treatment. Given this support, the requested Intracept procedure at L5-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested Intracept procedure at L5-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc One injections for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity for the Synvisc One injections. The peer-reviewed medical literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with advanced osteoarthritis of both knees. She had failed to respond to other conservative treatment including anti-inflammatory medications, physical therapy, and activity modification. The patient had undergone prior viscosupplementation series with marked pain reduction and documented functional improvement. Pain had recurred and resulted in significant functional difficulty in walking. The patient was attempting to avoid or delay bilateral total knee replacement. Therefore, the Synvisc One injections were medically necessary for treatment of the patients medical 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 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: Medical Necessity
Decision: Overturned

The patient is a 54-year-old female who is 53 weighing 226 pounds with a body mass index (BMI) of 41. She has comorbid conditions of hypertension, gastroesophageal reflux disease, and degenerative joint disease. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. She is requesting authorization for a duodenal switch procedure. The Health Plan has denied this request and in the alternative authorized Roux-en-Y gastric bypass. Peer-reviewed literature demonstrates duodenal switch has superior long-term outcomes and quality of life compared to Roux-en-Y gastric bypass. In addition, the incidence of weight regain is much higher for patients who undergo Roux-en-Y gastric bypass than those who undergo duodenal switch. Furthermore, there is less likelihood of complications with duodenal switch than with Roux-en-Y gastric bypass. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee has requested inpatient detoxification treatment for the treatment of his alcohol dependence, opiate dependence and marijuana dependence. Findings:  The physician reviewer found that there was no clear indication for inpatient treatment. Additionally, the patient demonstrated motivation for treatment. He tolerated Suboxone well, and the therapies that he received could have taken place on an intensive outpatient program basis. The services at issue were not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100 mg-40 mg, three tablets daily for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment-naive genotype 1a patients should be treated with Mavyret three tablets daily for eight weeks. These 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. The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Mavyret 100 mg-40 mg, three tablets daily for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested for a coronary CT angiogram for evaluation of her chest pain.   Findings:  Three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and it is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. CT angiography is also not a medically acceptable substitute for coronary angiography, as CT angiography does not accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary disease in this subset currently remains an experimental/investigational application of this technology.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system. Mitotic rate may add to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. DecisionDx-Melanoma assay classifies that particular melanoma based on the risk of metastasis over five years. On 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Additionally, it is not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma assay was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Demerol, morphine, or Dilaudid injections for treatment of the enrollees migraine headache pain. Findings: The physician reviewer found that the patient has a history of headaches since childhood, with patterns consistent with migraine. The patient reports that her attacks are relatively infrequent, but can last days at a time. The medical records do not summarize all of her previous treatments. She has used Maxalt as abortive, and injectable opiates as rescue. The patient had a recent emergency room visit and diagnosed with urinary tract infection and migraine. The independent medical review application indicates that she has been given injectable narcotics for home use in the past. The Health Plan has denied her request for Demerol, Dilaudid, or morphine for home injection.  Other treatments such as Toradol, steroids, dihydroergotamine injection were suggested. Valium tablets were also suggested.  She has been prescribed oral opiates including Dilaudid tablets.  Referral for chronic pain management was recommended to her. Instead the patient requests Demerol, morphine, or Dilaudid injections. The Health Plan denied the requested medications as not medically necessary for treatment. This denial is the subject of this appeal and determination.Final Result: The reviewer determined that the requested medications 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 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

The parent of a 17-year-old male enrollee has requested for behavioral health intensive outpatient program services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that an IOP is unique in that it offers a much-needed intermediate level of care for adolescents who have needs that are too complex to be effectively managed in an office outpatient setting, but who do not meet the threshold warranting inpatient hospitalization. At the same time, the IOP provides an alternative for providers seeking behavioral health care for patients in a less restrictive setting than inpatient treatment. For some adolescents, IOP serves as the point of entry to psychiatric care. For others who are already engaged in treatment, it provides crisis stabilization when outpatient treatment alone is insufficient or ineffective. The IOP appeals to parents, patients, and providers due to its ability to provide a wide array of services in a relatively short period of time.