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

A 66-year-old female enrollee has requested facet block injections for treatment of her low back pain.  Findings:  The physician reviewer found that The imaging studies are significant for multi-level lumbar degenerative disc disease and neural foraminal stenosis. It is difficult to determine the true pathology of the patients chronic pain based on an essentially normal physical examination without mention of findings on facet loading and imaging studies.  In addition, the medical literature shows evidence for diagnostic lumbar facet injections in treating facet syndrome. Ackerman and colleagues noted that non-radicular pain may be difficult to accurately diagnose and treat. The facet joint as a source of low back pain is controversial.  The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic. These authors performed a randomized controlled trial to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections. The results demonstrated that local anesthetic injections are useful for the diagnosis of non-radicular low back pain, but may yield false positive results with respect to lumbar facet pain depending on the technique utilized.  The current medical evidence does not support the services at issue in this clinical situation. All told, facet block injections provided on the date in question were not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a referral to a neurogastroenterologist for treatment of his chronic gastrointestinal (GI) issues.  Findings:  The physician reviewer found that the records document that this patient has experienced worsening constipation and incomplete defecation. Anatomic and functional reasons for his symptoms need to be evaluated. For diagnosis, he will need specialized evaluation and may need referral for testing such as defecography or balloon expulsion test. Neurogastroenterology is the medical specialty that diagnoses and treats patients with disorders of gastrointestinal motility and gastrointestinal function, including irritable bowel syndrome, which is one possible cause for the patients symptoms. Given that the patient has been evaluated by a number of gastroenterologists without a diagnosis or effective treatment, referral to a specialist in neurogastroenterology is warranted. Accordingly, the requested referral to a neurogastroenterologist for evaluation and treatment of his functional bowel syndrome is supported as medically necessary. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation 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

The patient is a 54-year-old man with end-stage liver disease secondary to hepatitis C, currently inactive on the liver transplant list because of morbid obesity. The patient was under the care of a hepatologist for several years. The patient is requesting that he continue to be treated by a hepatologist. The submitted records indicate the patients care is being managed by his internist and gastroenterologist. The patient has been advised that he needs to decrease his weight to 225 pounds or a body mass index of 35 before he can be re-listed on the liver transplant list.  In light of this, the Health Plan has indicated that the patient does not need to be followed by the transplant teams hepatologist at this time; the Health Plan states that a gastroenterologist is qualified to treat the patients liver condition, which is stable.The treatment proposed by the Health Plan is medically reasonable and appropriate. The patients liver condition is stable. No evidence has been provided that demonstrates that the patient cannot be appropriately treated by a gastroenterologist. Accepted community standards indicate a gastroenterologist is fully qualified to provide ongoing care of the patient at this time. Until such time as the patient loses weight and is re-listed on the liver transplant list, there is no medical indication for continued treatment by a hepatologist. Therefore, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. There is a lack of clinical studies in current medical literature demonstrating that strategies to correct the residual risk potentially identified by novel lipoprotein testing, such as the service at issue, will further reduce cardiac risk. It remains unclear if that such testing adds significant actionable information to what is already known from a fasting lipid panel. Researcher notes that while some practitioners use advanced lipoprotein analysis with the goal of better predicting risk and individualizing lifestyle and drug therapy for cardiovascular prevention, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) particle number and size, other lipoprotein subfractionation, apolipoproteins (apo) B and A, and lipoprotein(a) have not yet met current standards for biomarker evaluation, and it remains to be determined whether these tests incrementally add to cardiovascular risk predicted by traditional risk factors. Medical literatures report that only slight reclassification improvements in risk assessment are realized by adding apoB or lipoprotein(a) to conventional risk factors. In this clinical setting, there is insufficient evidence to support the use of the service at issue, particularly given this patients borderline risk. Therefore, advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying CALOCUS, this patient does not meet the criteria for RTC level of care services. The patient was at some risk of harm (score 2) due to past cutting, recent suicidal ideation without intent or plan, as well as some impulsivity without serious harm to herself or others. The patient has demonstrated moderate functional impairment (score 3) given to conflict with her parents and recent decline in her weight and appetite. The patient has mild comorbidity (score 2) considering her substance use and mental health issues. The patients recovery environment has been mildly stressful (score 2) due to family conflict, and the patients struggles with boundaries and limits. The patients environmental support has been limited (score 3) as the records noted the patient has a lack of access to appropriate care in her area. The patient has shown moderate resiliency to treatment (score 3) with continued symptoms despite long-term outpatient medication management and a recent psychiatric hospitalization. The patient has been incompletely engaged in treatment (score 3) as she has limited insight and minimizes her symptoms and problematic behaviors. This gives the patient a composite score of 18, which is consistent with high intensity community based services, such as intensive outpatient program (IOP) level of care. All told, the RTC services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Euflexxa medication. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis of both knees. The medication at issue was the third injection of a series of three Euflexxa injections. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the medication at issue was medically indicated. Therefore, Euflexxa medication was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the mediation at issue was 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

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement and prospective authorization and coverage for ultrasound, sclerotherapy and anesthesia performed for treatment of the enrollee who has a history of varicose veins and Klippel-Trenaunay syndrome. Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the services at issue in this clinical setting. This patient has been diagnosed with KTS and it is considered standard to treat lesions that are painful and localized for adequate venous drainage. KTS is a relatively rare condition, and there are limited universal treatment guidelines. However, there is sufficient medical literature to support the use of sclerotherapy for treatment of lesions associated with KTS. These studies have shown that sclerotherapy in patients diagnosed with KTS have been effective. As such, the ultrasound, sclerotherapy and anesthesia performed were and are medically necessary for treatment of this patients medical condition. 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 vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rinvoq ER 15mg tablets.The requested medication, Rinvoq, is a JAK inhibitor that is similar to Xeljanz (tofacitinib) for the treatment of rheumatoid arthritis. 2015 American College of Rheumatology (ACR) guidelines for the treatment of rheumatoid arthritis recommend methotrexate (MTX) +/- a TNF inhibitor (TNFi) as the next treatment in those who have failed methotrexate alone. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe rheumatoid arthritis. There is evidence that a 2nd TNFi is effective in those who have tried and failed a previous TNFi or for those who have had adverse reactions to other TNFi. There is also newer literature that demonstrates that tofacitinib and methotrexate combination therapy was non-inferior to adalimumab and methotrexate combination therapy in the treatment of rheumatoid arthritis in patients with an inadequate response to methotrexate. Another study demonstrates that tofacitinib is helpful in biologic naive and biologic non-responders. Although it is not inferior to Humira and is efficacious in previous biologic non-responders, the current guidelines continue to recommend a 2nd TNFi over a JAK inhibitor. In this case, however, the patient has a contraindication due to her end stage renal disease and pulmonary fibrosis. Under these circumstances, a JAK inhibitor would be preferred due to its better safety profile. Accordingly, the requested medication, Rinvoq ER 15mg tablets, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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: Overturned

The parent of a 17-year-old female enrollee has requested reimbursement for residential care services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient was admitted with a high risk of recurrence of self-harm behavior. She had already made one suicide attempt by overdose, and even after treatment for one week in acute hospitalization, she became frustrated and made a second very serious attempt to slash her own throat. She also had a long history of severely cutting herself at times despite interventions from various providers. Given her history of repeated attempts to harm herself in spite of multiple interventions, requires that she achieve stability before being discharged home to the same type of environment as before. Overall, the monthly summaries indicate disturbing symptoms including distortion of reality and poor coping skills until improvement was noted in the records approximately five moments after admittance. At that point, the patient showed enough improvement in dealing with her own emotions that she would have been safe to be discharged to a lower level of care without a deep concern that she would relapse. Before this date, however, the concern that she would relapse if discharged to a lower level of care indicates that she met the criteria for continued stay in an RTC facility. Prior to improvement noted after five months, the patients poor reality testing prevented her from being manageable at an available lower level of care. However, each summary demonstrates that she continued to make progress, developed insight, and was able to leave on passes with her family and have a successful time when doing so. For these reasons, the RTC services provided to this patient from admittance until the date on which she was noted to have improved were medically necessary, but services after that date were not medically necessary for management of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has experienced sudden vision loss symptoms of the left eye. The patient was diagnosed with retinal detachment and macular pucker in the left eye. He underwent repair of retina detachment, pars plana vitrectomy, membrane peeling, air fluid exchange and gas to the left eye. At issue, is whether the retina surgery that was provided were emergency services?Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition is manifested by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.In this case, the patient presented to the facility with a detached retina and sudden loss of vision in the left eye. A detached retina is a severe, acute condition. Failure to provide immediate medical attention could result in permanent loss of vision. Therefore, criteria for an emergency medical condition have been met. Because the patient had an emergency medical condition, the services provided were emergency services as defined under California law.Final Result: The reviewer determined the patient did receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology, 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

A fifty-three year-old female with a history of degenerative joint disease and chronic pain is requesting reimbursement and prospective authorization for Subutex.  Reviewers Findings:The reviewing physician found that treatment of chronic pain with Subutex is not an unreasonable alternative when (1) more standard medical management has failed to provide relief and (2) the patients care is managed by the appropriate specialist. The available records do not indicate that either of these prerequisites has been satisfied.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Prometheus testing for Crohns Disease. A review of the records indicates the patient has a history of Crohns Disease and is on immunosuppressant therapy. The patient had two perianal fistulas and originally was on budesonide without improvement.  She began Remicade every 8 weeks. However, two years later she had antibodies present with low levels and medication was reduced to every 5 weeks.  She had a follow-up colonoscopy and additional inflammatory markers.  The laboratory studies revealed mildly elevated inflammatory markers and the colonoscopy showed two small ulcers.  Infliximab was increased. Later, it appeared the patient was in clinical remission. It was recommended that she have her infliximab levels checked to maintain the current regimen. Her gastroenterologist indicated the blood test from Prometheus Laboratories is necessary to check for Remicade levels and antibody formation, and that this is the only way to determine if the patient has adequate levels of Remicade in her blood.  One reviewer did find that the literature supported the measurement of antibodies and infliximab concentration impacts management and is clinically useful.  However, two reviewers indicated the medical literature found that after dose optimization continued concentration-based dosing was not superior to clinically based dosing for achieving remission after 1 year. This patient was stable, had two previous tests which have shown an elevated level of Remicade and no antibiodies. Nothing had changed with her treatment and there is nothing to support performing this test again.Final Result: Two 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 Internal Medicine and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the presence of dense breast tissue is an indication for tomosynthesis. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. Therefore,  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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:  All three physicians are board certified in diagnostic radiology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical conditions and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.