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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing. Findings:  The physician reviewer found that Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines recommend broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, Guardant360 testing was likely to have been superior over other available methods of evaluating this patient. Final Result: Two of 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: 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: Overturned

Nature of Statutory Criteria/ Case Summary: This is a female that was seen by podiatry and diagnosed with posterior tibial tendonitis and pes planus (fallen arches) to both feet. The examination reports moderate loss of foot arch with a medical shift bilaterally and tenderness to the posterior tibial tendons bilaterally. She reports that her foot pain is relieved with rest and orthotics, and that her orthotics are broken down. Podiatry recommends new functional orthotics to control the potential collapse secondary to her pes valgus deformity. At issue is whether the custom molded orthopedic shoe inserts are medically necessary to treat the patients medical condition. The use of functional custom molded orthotics (shoe inserts) for the treatment of a patients pes planus and posterior tibial tendinitis is widely accepted across literature and is an effective conservative solution for these diagnoses. Custom molded orthotics will take the pressure off the first toe joint to help reduce pain. The rational for custom orthotics versus prefabricated (over the counter or OTC) arch supports is that OTC arch supports do not control the biomechanical forces (movement) on the foot and do not contour to the patient's feet. The patient has posterior tibial tendinitis and a calcaneovalgus deformity, which needs to be controlled with a semi-rigid material, a deep heel and possibly a medial flange to prevent foot collapse. These specifications cannot be found in a prefabricated arch support. As noted in the literature, almost all of them used some form of orthosis with or without physiotherapy. They note that studies used various custom orthoses including the University of California biomechanic lab orthoses. The record provided for review notes that the patient has orthotics that are no longer effective in supporting the arches and taking pressure off the posterior tibial tendon. The patient and physician report that she has benefited from custom orthotics with reduced pain, and increased function. Literature reports that custom orthotics may help to avoid any further, more serious issues, such as the need for surgery, in the future. Therefore, based on literature and the medical record provided for review, custom molded shoe inserts (orthotics) are indicated for the patient in the treatment of pes planus and posterior tibial tendinitis. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatry 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female enrollee has requested speech therapy services for treatment of the enrollees mixed receptive/expressive language delay and expressive speech delay consistent with childhood apraxia of speech. Findings:  The physician reviewer found that verbal apraxia, or apraxia of speech, is an impairment involving planning and coordinating movements for speech production. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. This type of impairment is frequently seen after stroke or with congenital disorders that affect the brain such as Down syndrome, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, these children are at risk for reading and spelling problems in addition to the articulation problems. Communication at all levels may ultimately be impaired.  The literature supports the use of intensive speech and language therapy for verbal apraxia as well as expressive language delay.  In this patients case, all speech therapy services provided during the time period at issue were medically indicated.  Additionally, continued speech therapy services at the requested frequency are medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for myocardial perfusion imaging (CPT 78451). Based on the records reviewed, this patient has increased coronary risk and symptoms suspicious for coronary ischemia. His electrocardiogram was mildly abnormal. He has been unable to ambulate on a treadmill to complete testing. In the clinical circumstance of an intermediate likelihood of coronary ischemia, further evaluation with stress testing is appropriate and considered standard accepted practice in the medical community. Since this patient is unable to ambulate on a treadmill, a pharmacologic stress test, such as the requested persantine nuclear stress test, is appropriate for further evaluation. Therefore, the requested myocardial perfusion imaging (CPT 78451) is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 subspecialty certification in cardiovascular disease 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 male enrollee requested Sovaldi 400mg per day and Olysio 150mg per day for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. Based on published evidence of safety and efficacy, the requested Sovaldi 400mg per day and Olysio 150mg per day are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested wireless capsule endoscopy of the gastrointestinal tract for medical evaluation of her abnormal weight loss with lower abdominal pain and history of celiac disease.   Findings:  Two physician reviewers found that in this patients case, the indication for wireless capsule endoscopy is not her abdominal pain, but to reassess her celiac disease that has proven symptomatically refractory to gluten restriction. Accordingly, the requested wireless capsule endoscopy is likely to be more beneficial for evaluation of the patients medical condition than any standard approach.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a male enrollee requested 36 hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Two physician reviewers found that the patient attends elementary school five days per week in addition to ABA therapy. There is a lack of documentation submitted for review demonstrating a need to increase ABA services to 36 hours per week. Based on the clinical documentation submitted for review and medical literature, 25 hours per week of ABA services is appropriate and medically necessary for this patient. As such, the request for ABA therapy at the requested frequency of 36 hours per week is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Studies concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Studies conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. In this case, the patient presents with a history of severe bilateral knee osteoarthritis. He has been treated every 6 to 12 months since 2014 with bilateral Synvisc injection series. His last injection series reported 80% improvement in pain and functional benefit allowing him to maintain an active lifestyle. He has requested additional viscosupplementation injections to delay total knee replacements. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and to assist in delaying total knee replacement, repeat Synvisc injections are indicated. Therefore, the requested Synvisc One injections are medically necessary for treatment of the patients medical condition. 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 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 patients parent has requested reimbursement for intensive outpatient program (IOP) psychiatric 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. Using CALOCUS, 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) developmental, medical, substance use 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. The patients composite score is consistent with high intensity community based services. This level of care is consistent with the IOP level of care. Given these findings, the IOP psychiatric services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Upheld

A 54-year-old female enrollee has requested trigger point injections for the treatment of her pain. Findings:  The physician reviewer found that the patients condition is discogenic in nature. Trigger point injections are used only for myofascial pain, not discogenic pain or any other pain. The submitted documentation does not support the presence of myofascial neck or shoulder pain. Furthermore, the American College of Occupational and Environmental Medicine guidelines do not support the use of trigger point injections for neck pain. Thus, trigger point injections are not medically indicated for treatment of this patient. There are other modalities that are more appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested individual occupational therapy services for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the current medical evidence supports the requested individual occupational therapy services in this patients case.  This patient has global delays in fine motor skills, adaptive skills and language as a result of Down syndrome.  On the said date, evaluation revealed fine motor skills at the six-month level. Children with Down syndrome often demonstrate difficulties in the areas of strength, balance and visual motor skill control.  These children often have delays in overall gross motor and fine motor skills. With its focus on teaching motor planning skills and facilitating the development of fine and gross motor skills, occupational therapy is well-suited to benefit this patient. All told, the requested individual occupational therapy services are medically indicated in this patients case.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for individual out-of-state counseling services.California Health and Safety Code  1345(h) states that, `Out-of-area coverage  means coverage while an enrollee is anywhere outside the service area of the plan, and shall also include coverage for urgently needed services to prevent serious deterioration of an enrollees health resulting from unforeseen illness or injury for which treatment cannot be delayed until the enrollee returns to the plans service area.`In this case, the patient's mood changes, defiant behavior, and her conflict with her mother were noted to be chronic. The patient had been sent out-of-state by her mother due to concerns about the same behaviors and symptoms that were addressed in outpatient therapy. The patient had been living out-of-state for almost one month prior to starting outpatient psychotherapy there. Records for the patients first counseling appointment state that the patient was referred for difficulties cooperating with rules and respecting her mothers boundaries, for conflict and tension in her relationship with her mother, and for skipping class. The submitted documentation reflects that the patients out-of-state therapist did not report any safety concerns. There was no report of any unsafe behavior or deterioration occurring while the patient was living with her grandparents out-of-state. In addition, no unforeseen illnesses or injuries were noted to have occurred while the patient was out-of-state. Therefore, the individual out-of-state counseling services at issue were not urgent care services, defined as services to prevent serious deterioration of the patients health resulting from unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the Health Plans services area.Final Result: The reviewer determined that the services at issue were not urgent care services. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Restasis for treatment of the enrollees medical condition. Findings: The physician reviewer found that according to the documentation submitted for review, treatment with Restasis for this patient has not been established medically necessary. There is scant evidence in the medical literature that supports Restasis for the treatment of peripheral ulcerative keratitis that is resistant to other forms of treatment. In addition, there is a lack of evidence linking Restasis as a preventive or prophylactic treatment for peripheral ulcerative keratitis or Terrien marginal degeneration. In sum, the requested Restasis is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 24-year-old female enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that Final Result: The reviewer determined that the enrollee did not receive psychiatric emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. At issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The patients diagnoses included acute psychiatric needs for major depressive affective disorder, recurrent episode, without mention of psychotic behavior, anxiety disorder, unspecified, panic and worry, and self-injury behavior, self-cutting. While psychiatric services may have been indicated, there is a lack of evidence that treatment in a less restrictive setting would have been inadequate to safely address the patients issues. Moreover, there is no documentation that the patient has failed treatment in a less restrictive setting. Thus, the PHP services were not provided for the treatment of a psychiatric medical emergency. 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: Upheld

A 49-year-old male enrollee has requested for hypnotherapy for treatment of his irritable bowel syndrome and fibromyalgia. Findings:  Two physician reviewers found that there is insufficient evidence demonstrating the superior efficacy of the requested services over other available treatment alternatives. The literature notes an association between psychological conditions, including depression and anxiety, with fibromyalgia and irritable bowel syndrome, but there is inconclusive evidence as to the benefit of hypnotherapy in these conditions.  Zijdenbos and colleagues performed a review of literature on psychological treatments for irritable bowel syndrome. The authors noted that most studies suggest that these therapies are not superior to placebo, and the sustainability of their effect is questionable.  All told, the requested hypnotherapy is not likely to be more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs surgery for treatment of the enrollee who was diagnosed with a nodular basal cell carcinoma. Findings:  The physician reviewer found that there is support in the medical literature for the requested procedure in this clinical setting. The patient requested Mohs surgery for the treatment of a basal cell carcinoma which is located on the left side of her nose.  The guidelines indicate that Mohs surgery is recommended for treatment of basal cell carcinoma involving the head and neck, irrespective of the size of the lesion. The size of the biopsy specimen is not necessarily related to the size of the lesion. The pathology specimen was 2 mm (after shrinkage which occurs in the skin once removed from the body). The clinical record indicates that the lesion is 7 mm in size and not 2 mm in size.  Additionally, the location of the lesion is complicated because it is located in the alar groove. Given the diagnosis and location of the lesion, the recommended treatment for complete removal of this tumor is Mohs micrographic surgery. Therefore, the requested Mohs surgery is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.