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

The patient has requested authorization and coverage for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS guideline, this patient meets the criteria for IOP services. This gives the patient a composite score which is consistent with medically monitored community based services. 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 with subspecialty certification in addiction medicine 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 45-year-old female enrollee has requested robotic assisted total hysterectomy (da Vinci surgery) for treatment of her uterine fibroids. Findings:  Two physician reviewers found that the use of robotic assistance for gynecologic laparoscopic procedures has been expanding, but for the vast majority of gynecologic surgeries, the additional access ports, and surgical time have not justified its routine use. There may be advantages with certain gynecologic oncology procedures relating to endometrial cancer and cervical cancer requiring node dissection, where the robot has allowed the laparoscopic approach where the alternative was an open procedure. Similarly, some pelvic reconstructive surgeries such as sacrocolpopexies may be better performed with the robot. The current evidence demonstrates the safety and feasibility of the robotic approach for gynecologic surgery (Song and colleagues). However, the authors noted that prospective trials are needed to compare the efficacy against conventional laparoscopy and to help determine not only who should be doing robotic assisted surgery, but also for which applications.  The use of robotically assisted techniques in gynecology have been shown to be a safe and effective alternative to conventional laparoscopic surgery (Bocca and colleagues). However, the authors noted that whether or not to approach the management of certain gynecological pathologies with a laparotomy or laparoscopy (conventional or with robotic aid) continues to be a point of debate, and long-term analysis of outcomes is ongoing. Thus, although the robotic approach can be considered generally safe (with similar risks to routine laparoscopic procedures), it is not uniformly appropriate for most gynecologic abdominal procedures.  It has not been proven to be of greater benefit for most procedures.  Based on current standards, the use of the robotic device for the patients procedure is not standard of care.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 16-year-old male enrollee requested authorization and coverage of residential treatment for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested services are not medically necessary for treatment of the enrollees substance abuse and behavioral health problems.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Exondys 51 (eteplirsen) weekly infusions. Findings: Muscular dystrophies are an inherited group of progressive muscle disorders whose etiology stem from dysfunctions in genes associated with normal muscle function. A study noted that mutations in the Duchenne muscular dystrophy (DMD) gene result in Duchenne or Becker muscular dystrophy due to absent or altered expression of the dystrophin protein, with severe DMD typically presenting around ages two to five with gait disturbance, historically leading to the loss of ambulation by age 12. The U.S. Food and Drug Administration (FDA) approves the use of Exondys 51 (generic name eteplirsen) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 51 skipping. Another study noted significant, clinically meaningful attenuation of respiratory decline, measured by percent predicted forced vital capacity (FVC% p), in patients treated with eteplirsen. In this case, the patient has a diagnosis of DMD amenable to exon 51 skipping. In this clinical setting, the requested medication is medically indicated. Therefore, for Exondys 51 (eteplirsen) weekly infusions are 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 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

A 25-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male has requested coverage for past and future transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  The physician reviewer found that based on review of the available records, this patients depression is treatment resistant as multiple antidepressants and augmentation strategies have not successfully brought on remission. In the medical literature, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provides evidence that TMS is a safe and effective treatment for major depressive disorder. The APA Practice Guidelines for treatment of depression state that the (A)cute phase treatment may include TMS. Connolly and colleagues found that, TMS was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression. Carpenter and colleagues reported that, TMS is an effective treatment for those unable to benefit from initial antidepressant medication with a response rate of 58.0% and a remission rate of 37.1%. Thus, although relatively new, TMS is an effective treatment as demonstrated in the referenced evidence based literature, and is FDA approved for the treatment of treatment resistant major depressive disorder. Consistent with these findings, TMS treatment from the date at issue and forward was and is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested growth hormone (GH) therapy for the treatment of her GH deficiency. Findings:  The physician reviewer found that the patient has a history of IGF-1 levels in the low normal range and underwent pituitary surgery for a presumed ACTH-producing pituitary tumor. One of two GH stimulation tests supports the patients diagnosis of GH deficiency. Furthermore, the patient has developed diabetes insipidus, which indicates an antidiuretic hormone (ADH) deficiency. In sum, this patient is an appropriate candidate for GH therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 35 hours per week of direct applied behavioral analysis (ABA) therapy (CPT code H2019) at the frequency of five days per week. Findings:  The physician reviewer found that the request for 35 hours per week of direct ABA therapy (CPT code H2019) at the frequency of five days per week provided during the dates of service in question were and are medically necessary to address the patients maladaptive behaviors that pose a danger to the patient. According to the documentation submitted for review, the patient presents with elopement, and licking and chewing nonedible items. ABA therapy as recommended by the treating provider is medically appropriate for treatment of the patients autism. All told, the request for the services at issue were not and are not medically necessary for 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: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested authorization and coverage for sympathetic nerve block by use of Botox injections and a CT lumbar spine without dye for evaluation and treatment of the enrollees complex regional pain syndrome. Findings:  Three physician reviewers found that the patient is a 47-year-old female who has requested authorization and coverage for a sympathetic nerve block by use of Botox injections and a CT lumbar spine without dye.  The Health Plan has denied this request and reported that the requested services are investigational in this patients case.  Per the submitted documentation, the patient has been diagnosed with complex regional pain syndrome.  The medical records noted that the patient improved with Toradol injections.  The documentation indicated that a prior sciatic nerve block did not result in pain relief.  In this clinical setting, the superior efficacy of the requested sympathetic nerve block by use of Botox injections and CT of the lumbar spine without dye has not been established.  The medical records noted complex regional pain syndrome in the left lower extremity.  The current medical literature has not demonstrated the superior effectiveness of the use of Botox for this patients medical condition.   Carroll and colleagues conducted a study evaluating whether botulinum toxin A would prolong analgesia after sympathetic blocks in patients with complex regional pain syndrome.  The authors concluded that botulinum toxin A prolonged the analgesia from sympathetic block in the preliminary study.  However, Safarpour and colleagues investigated the efficacy of botulinum toxin A in allodynia of patients with complex regional pain syndrome.  The authors noted that none of the patients with allodynia showed a significant response after treatment. The treatment was painful and poorly tolerated, per Safarpour and colleagues.  All told, the requested sympathetic nerve block by use of Botox injections and a CT lumbar spine without dye are not likely to be more beneficial for evaluation and treatment of this patient than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) treatment for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient had been sober for approximately two months on admission. He reported that he was irritable, anxious, and had insomnia. He had no behavioral, emotional, or cognitive issues, and he was medically and psychiatrically stable. The patient lived with his mother who had opioids in the home for pain management. He required an additional degree of treatment to provide an environment where he could further develop coping skills in setting of living in an environment containing opioids. In addition, he had social anxiety. The patient required PHP treatment to assist him with becoming more comfortable in the group setting which is essential in relapse prevention. He was no longer reserved and he was able to discuss tools to use to remain sober. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine 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 64-year-old male enrollee has requested robotic laparoscopic prostatectomy for the treatment of his high-risk prostate cancer. Findings:  The physician reviewer found that robotic-assisted laparoscopic prostatectomy has advantages over conventional surgery and was likely to provide increased benefits for this patient. Given the extensive nature of the patients disease and his history of thrombocytopenia, the use of robotic assistance was a safer option than standard surgery. The decision to perform robotic laparoscopic prostatectomy was medically appropriate and clinically indicated in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center (RTC) services for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patients record shows that the patient was not a danger to herself or to others and she was not violent. Furthermore, there was no level of substance abuse that imminently endangered the patient and her substance abuse problem was not a significant focus of this patients treatment. The patient was able to physically care for herself and she was cognitively intact. There was no evidence of emotional, cognitive, or behavioral dysregulation to a degree which required 24 hour care. The record further states that the patient and her family were working together in their therapies and her home environment was supportive. Although the patient continued to struggle with feelings of vulnerability, emotional dysregulation, and inadequate social skills, the patient was appropriate for continued treatment at a less intensive level of care. The records do not establish that stepping the patient down to a lower level of care would have resulted in significant deterioration of her condition. For the reasons stated above, the services at issue were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. 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: An enrollee has requested transcranial magnetic stimulation (TMS for treatment of the enrollees major depression.  Findings: The physician reviewer found that based on peer-reviewed medical literature, TMS is a non-invasive brain stimulating procedure utilized in the treatment of patients with major depressive disorder. The procedure has been approved by the U.S. Food and Drug Administration (FDA). In addition, TMS tends to be well tolerated with fewer barriers and side effects than electroconvulsive therapy. TMS is likely to prevent the need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression. Further, the American Psychiatric Association (APA) has endorsed use of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. All told, the requested TMS is supported as medically necessary for treatment of this patients major depressive disorder.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 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: Upheld

A 64-year-old male has requested the medication Vytorin for the treatment of his high cholesterol. Findings:  The physician reviewer found that with the records provided for review, Vytorin is not medically necessary. The patient has been taking Tricor and Vytorin (which contains Zocor). It may be quite possible that treatment goals are achievable with the medications Tricor and the current dose of Zocor (in the Vytorin) alone, without adding the zelia component. Since it is not clear that treatment goals cannot be met with Tricor and the current dose of Zocor that the patient is already receiving, treatment failure with Zocor has not been demonstrated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomography (CT) scan of the thorax. According to the published guidelines from the American Thyroid Association (ATA), CT thorax is not listed as an indicated imaging diagnostic tool for thyroid nodules. Per the ATA guidelines, an ultrasound was the appropriate imaging modality for evaluation of this patients thyroid nodule. There is a lack of clinical symptoms documented in the records provided to support possible spread of endometrial malignancy to the thyroid.  The treating provider did not indicate the CT was ordered due to any chest related symptoms. Per the position statement from the Society of Gynecologic Oncology (SGO), symptoms or clinical examination findings to support recurrence, spread of disease, or monitoring of active evidence of disease in the chest must be present to support use of CT of thorax. In the absence of documentation of these findings, the CT scan of the thorax was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.
Appeal type: Urgent Care
Decision: Upheld

An enrollee has requested reimbursement for hospital services. The Health Plan has denied this request indicating that the requested services were not emergent/urgent and were not authorized. 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 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 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 with symptoms that were not acute in onset but had been present for 10 days. The patient's symptoms were not sudden, acute, or severe. She denied any severe symptoms such as fever or shortness of breath. The patients treatment plan included over-the-counter medication. A lack of immediate medical attention would not have placed her health in serious jeopardy, nor was she at risk for serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The patient did not have an emergency medical condition as defined by California law. Therefore, the patient did not receive emergency medical services on the said date. Final Result: The reviewer determined that the services at issue were not emergent or urgent for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency medicine 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 65-year-old male enrollee has requested coverage for a past computed tomography angiography (CTA) of the coronary arteries for evaluation of his chest pain.  Findings:  Three physician reviewers found that the patient was evaluated with a coronary computed tomography angiogram (CTA) with documented indications of back discomfort, chest discomfort, abnormal electrocardiogram and dyspnea. The coronary CTA revealed coronary calcium but no significant obstructive coronary artery disease (CAD). No additional medical records are available for review. Initial standard evaluation for the indications mentioned in the report typically does not include coronary CTA. For example dyspnea, abnormal EKG and chest discomfort are usually initially evaluated more appropriately with other cardiac modalities such as stress testing or echocardiography (ECHO). Coronary CTA is medically indicated only in certain situations such as assessment of coronary anomaly or assessment of coronary anatomy in a low risk patient with equivocal stress test results. Without records to support the clinical necessity of coronary CTA, its use was not likely to provide novel and useful information relevant to this patients care beyond that attainable with standard alternatives.