Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox for treatment of the enrollees pelvic floor disorders.Findings: The physician reviewer found that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The treatment available for medication refractory overactive bladder disorders includes Botox injections, nerve stimulations therapy or augmentation cytoplasty. Of the options available, Botox injections are the least invasive and can be performed as an outpatient with immediate relief of symptoms. In this clinical setting, Botox injections are a reasonable treatment option for this patient and 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 service is 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: All three physician reviewers are board certified in urology and are actively practicing. The reviewer 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

A seventy-one year-old female with long-standing lumbar pain is requesting authorization for a kyphoplasty procedure.  The patient was seen by her surgeon for severe lower back pain and was noted to have a new L1 compression fracture, questionable nonunion and loosening of the fusion hardware.Reviewers FindingsOne of the reviewing physicians found that the patient does appear to have acute symptoms associated with the L1 vertebral fracture and she is an appropriate candidate for kyphoplasty.  This physician found that the Health Plan denial should be overturned.Two of the reviewing physicians found that it would be very difficult to determine how much pain she truly has from the compression fracture, and that the kyphoplasty procedure does not to appear to be indicated for this patient at this time.  Therefore, these reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a COVID-19 antibody test. The Centers for Disease Control (CDC) does not currently recommend antibody testing as the sole basis for diagnosis of acute infection. The CDC states that policies regarding testing are made at the state and local levels. The California Department of Public Health states that there are four tiers of priority for antibody testing. Tiers 1 and 2 focus on individuals with current symptoms. Tier 3 is for asymptomatic individuals who are essential workers or educational workers. Tier 4 is for individuals who are asymptomatic but at risk of getting the infection. Currently, there are over 91 manufacturers of serologic tests for SAR-CoV-2, without well-delineated performance characteristics. In their review of serologic tests, researchers further suggest that false positive rates are concerning. Finally, given the uncertainty of the immunology of the virus, the interpretation of serologic findings can be problematic. In this case, the patient does not fit California Department of Public Healths four tiers of priority for testing. Further, the first cases of COVID-19 were recognized in December 2019. Thus, it is unlikely that the patient was exposed to COVID-19 in California earlier. Therefore, the requested COVID-19 antibody test is not medically necessary for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  Three physician reviewers found that she was asymptomatic with respect to her breasts.  She  underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, she had a hand-held whole breast sonography. The current images were compared to prior mammograms. An interval development of indeterminate calcifications and questionable architectural distortion in the mid outer portion of her left breast were noted.  Her breasts were described as average in density. Subsequent to study, it was recommended that the patient return for additional imaging. The patient requested reimbursement for the tomosynthesis portion of the breast examination. The Health Plan has denied reimbursement for digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the presence of new indeterminate calcifications and a possible area of architectural distortion are both reasonable indications for tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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 reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee requested physical therapy for medical treatment of the enrollees developmental delay.  Findings:  The physician reviewer found that the current medical evidence supports the requested physical therapy in this clinical setting.  The report by Hagen and colleagues evaluated the evidence regarding the effects of exercise therapy on physical function and pain for patients with musculoskeletal conditions. The authors noted that exercise therapy has beneficial clinical effects for musculoskeletal conditions.  The submitted documentation indicated the patient was slow with his gross motor skills and had poor trunk control.   The clinical notes indicated the patient was unable to walk backward, run, or walk up stairs.  In this case, the requested physical therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has a four-year history of depression.  Her symptom complex includes persistent depressed mood and hopelessness, poor sense of self and negative schemas, weight gain, tearfulness, and sleep problems.  In terms of past psychiatric treatments, the patient is reportedly active in psychotherapy.  Electroconvulsive therapy was considered but not pursued.  The patient has trialed multiple psychotropic medications, including fluoxetine, sertraline, escitalopram, lithium, Trileptal, Depakote, Abilify, Seroquel, Saphris, Zyprexa, thyroid hormone, and buspirone.  Psychopharmacotherapy has not achieved remission.  Due to persistent affective symptomatologies, the patient was referred for transcranial magnetic stimulation.  The Health Plan has denied coverage for transcranial magnetic stimulation and reported that the requested services are investigational for the treatment of this patient. Although this fairly new treatment technology lacks a robust heterogeneous evidence base at this stage of implementation, the literature supporting transcranial magnetic stimulation in terms of volume, quality, and range of investigation continues to grow.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, in this patients case, the documentation does not demonstrate the superior efficacy of the requested services.  The mood stabilizing augmentative strategies were thorough, but the only primary antidepressant class utilized was selective serotonin reuptake inhibitors.  In this clinical setting, transcranial magnetic stimulation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested a computed tomography (CT) scan and a magnetic resonance imaging (MRI) scan for an evaluation of her migraines and vertigo. Findings:  The physician reviewer found that this patient has had years of headache and dizziness. She has been diagnosed as having migraine, vertigo and tinnitus. Ear, nose, and throat testing had not suggested a retro-cochlear lesion. Prior imaging of the brain was normal. Evidence-based guidelines support the use of brain imaging in individuals with recent onset headache, with distinct change in headache pattern, or with abnormal findings on neurologic exam. Here, a neurologic exam is not recorded. The need for subsequent imaging of the brain is not supported by factors such as documented exam abnormalities, or unexplained change in headache pattern. All told, the necessity of the imaging studies performed are not documented in the clinical records provided.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested automated nerve conduction testing for evaluation of her history of spinal stenosis, spondylolisthesis, sciatica, osteoarthritis and intervertebral disc degeneration.  Findings:  Three physician reviewers found that the patient had undergone spine surgery. During the surgery, the surgeon requested automated nerve conduction testing. The records indicate that the patient underwent spine surgery with monitoring of nerve root function to insure that the integrity of nerve function was maintained.  Peer reviewed literature shows support of this monitoring in spine surgery. Researchers have noted that intraoperative neurophysiological monitoring and mapping represent an effective method of identifying and monitoring, in real time, the functional integrity of both the spinal cord and the nerve roots. Moreover, there was noted consensus by medical groups that this method of monitoring improved safety of the surgical procedure and reduced complication rates. 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: Reviewers 1, 2 and 3 are board certified in neurology 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 parent of a male enrollee has requested authorization and coverage for applied behavioral analysis (ABA). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The request for ABA is medically necessary for treatment of the enrollees autism spectrum disorder. Applied behavioral analysis (ABA) is a therapeutic intervention that must be customized to the needs of the individual patient and thus, there are no clear guidelines indicating a definitive number of hours per week of behavioral interventions such as ABA. It is also noteworthy to remember that cognitive plasticity exists through child development and adult life and ABA can continue to be of benefit to individuals with ASD as they move into adulthood. The patients provider documents the patient has steadily improved in his level of independence, communication and social skills while receiving ABA therapy per week. While the patient has been making gains, the provider notes he still continues to experience episodes of self-harm and occasional injurious actions toward others. In this case, the records demonstrate that continuation of ABA therapy at an intensive level is clinically indicated to prevent regression and maintain patient safety. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Monovisc injection. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for the treatment of the enrollees osteoarthritis of the hip (hip joint disorder). At issue in this case is whether the requested Monovisc is medically necessary for the treatment of the patients medical condtion. In this case, the patient reported left hip pain with magnetic resonance imaging evidence noted of osteoarthrits and labral tear. The patient previously underwent a left hip steroid injection with significant side effects to the steroid noted post-procedurally. The patient has now requested Monovisc as an alternative intra-articular injection. Monovisc is indicated for severe knee osteoarthritis and does not carry an indication for intra-articular injection. Therefore, the requested service is not medically necessary.Final Result: The reviewer determined that the requested services 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 anesthesiology with sub-specialty certification in pain management 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 Habit Reversal Therapy (HRT) for the treatment of his medical condition. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this clinical setting.  HRT emerged as a therapeutic intervention in the early 1970s.  HRT is becoming more common as it is a recommended treatment not only for tics, but for trichotillomania and excoriation disorder as well.  HRT is a structured package of clinical interventions, the most important of which is the application of a competing response whenever the patient notices either a tic or the urge to tic.  HRT is typically delivered with 8 to 11 individual sessions lasting 60 to 90 minutes each.  According to the medical literature, HRT has the strongest empirical support, among the behavior therapies, for reducing tics.  HRT is classified by the American Psychological Association as a well-established treatment for Tourettes syndrome.  It is reasonably expected that HRT will improve the patients condition.  All told, the requested services are medically indicated 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 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: A patient has requested reimbursement for the residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of a portion of the services at issue. This patient had an acute episode of illness that initially warranted inpatient psychiatric services. The hospital-based care provided was reasonably expected to improve the patients condition and prevent a more serious episode of illness. However, based on the medical records submitted for review, treatment at the acute level of care was no longer medically necessary after the first disputed date of service. On the first disputed date of service, the patient continued to endorse passive suicidal ideation. The patients family system was negotiating cultural and stigma issues related to mental illness and psychiatric treatment. Nonetheless, they were supportive and involved. The patient was engaged in active treatment. The patients new medications were both increased. Thus, discharge would have been premature at the time. On the second disputed date of service, the patient was anxious about returning home and consolidating the experience of the fathers care. The patient was looking forward to continuing treatment in a partial hospital program and believed it would begin the following day. The patient had an enjoyable visit with friends and played a board game.  The patient was sleeping well at night. There was no report of inappropriate or concerning behaviors on the unit. Neither the patients thought processing nor cognition were compromised. The record noted that the patients mood was normal and was negative for active or passive suicidal ideations. The patient did not require any rescue medication and there were no changes made to the daily regimen, which appeared to be well tolerated with no adverse drug reaction. On-going care was clearly necessary. However, after the first disputed date of service, there was no evidence of an acute psychiatric syndrome that service delivery in a less restrictive setting would have been unsafe or inadequate. As such, a portion of the residential treatment center services were medically necessary. 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 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 thirty-one year-old female with hyperhidrosis of the axilla is seeking reimbursement for the Botox treatments.  The patient had not responded to Drysol, but has had effective treatment with Botox.Reviewers Findings:The reviewing physician found that the evidence provided does not demonstrate that Botox injections were clinically indicated for treatment of this patients condition.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested extracorporeal shock wave therapy for the treatment of her medical condition.  Findings:  Two physician reviewers found that the medical evidence supports the requested services in this clinical setting.  This patient has Kohlers disease which is a condition affecting the vascularity to the navicular bones that has the potential of altering the shape and joint surfacing of an important mid-foot joint.  In this patients case, the records document failed conservative therapy.  In sum, the requested extracorporeal shock wave therapy is likely to be more efficacious than other treatment options.   Final Result: Two 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: All three reviewers are board certified in orthopedic surgery 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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by a researcher, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  In this patients case there was an indication for further evaluation.  One could have obtained further compression views to separate overlapping structures, but the breast tomosynthesis technique is a more optimal means to better evaluate a suspicious lesion.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   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 reviewers are board certified in diagnostic radiology 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.