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

The patients parent has requested authorization and coverage for bilateral breast reduction surgery (CPT 19318, modifier 50). The World Professional Association for Transgender Health (WPATH) states that chest surgery can be carried out earlier than age 18 in order to give adolescents an opportunity to experience and adjust to a more masculine gender role. The WPATH recommendations also state that refusing timely medical interventions might prolong gender dysphoria and contribute to stigmatization. In this case, the patient already has significant emotional distress due to the presence of breasts, which has led to social and developmental limitations. Current studies report that the quality of life and satisfaction after masculinizing breast reduction are significantly improved in adolescents with gender dysphoria, including in non-binary individuals, such as this patient (Mahfouda, et al.). The physician reviewer found that  improved quality of life and comfort with physical appearance for transgender female-to-male patients, as well as patients who identify as agender, such as this patient. This patient has a diagnosis of gender dysphoria persisting over the last four years, which has significantly affected education and social development. Consideration of the evidence and recommendations show that preventing or delaying the requested services may prolong or worsen the patients gender dysphoria. All told, the requested bilateral breast reduction surgery (CPT 19318, modifier 50) is medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45 year-old male enrollee has requested artificial disc replacement surgery for the treatment of his degenerative disc disorder. Findings:  Three physician reviewers found that lumbar artificial disc replacement remains experimental for the treatment of degenerative disc disease. Although research is on-going, the long-term safety and efficacy of the procedure has not been established. The majority of the procedures may appear to be  successful in the short term, but long-term outcomes are unknown and complications may be severe. Artificial disc replacement has not been shown to be more effective than non-operative therapy or lumbar fusion in the long-term.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) prostate ablation procedure that was performed. The Health Plan has denied the services at issue as investigational for treatment of the enrollees prostate cancer.Findings:  Three physician reviewers found that high-intensity focused ultrasound (HIFU) has been widely used for whole gland ablation. The first published results of focal HIFU are promising. The patient's quality of life and potency are well preserved with good early results. Whole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under five years of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments. The U.S. Food and Drug Administration (FDA) has approved HIFU as safe for the treatment of prostate ablation. However, there is no specific indication for the treatment of prostate cancer. Furthermore, the safety and efficacy of chemical or surgical cytoreduction of the prostate remains unproven. The safety and efficacy of HIFU are currently being evaluated. There is a paucity of long-term comparative clinical trials indicating that this form of treatment is superior to conventional treatment options. Thus, the HIFU prostate ablation procedure that was performed was not 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 procedure was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: The patient has requested authorization and coverage for lumbar/sacral facet joint radiofrequency neurolysis. Medical literature reported that the evidence for therapeutic facet joint interventions is good for conventional radiofrequency. In addition, Lee and colleagues found there was a reduction in pain 12 months post procedure for patients with facet joint disease of the lumbar spine. Moreover, Researchers concluded that RFA of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for 6-12 months and possibly up to two years. In this case, the patient has had a diagnostic medial branch block, which provided 80-90% relief for 24 hours before the pain returned. Based on the current guidelines, a positive response to one or two medial branch blocks, with at least 70% pain relief and/or improved ability to function for a minimal duration at least equal to that of the local anesthetic is required to proceed with RFA. However, more recent well-conducted systemic reviews have validated the benefit of RFA for facet arthropathy, as in this patients case. Based on the medical records available for review, the requested lumbar/sacral facet joint radiofrequency neurolysis is medically necessary for 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 anesthesiology with subspecialty 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested for bilateral breast magnetic resonance imaging for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that breast MRI is a useful adjunct to standard imaging (including mammography and breast ultrasound) in select patient populations. For screening breast MRI, the American Cancer Society (ACS) has published guidelines for the use of breast MRI in screening for breast cancer. These guidelines include patients with a strong family history of breast cancer, those with personal or family history of BRCA mutation and for those patients with a history of prior radiation to the chest as a child or young adult. The ACS does not support the use of screening breast MRI in patients with dense breast tissue and concluded that there is insufficient evidence to recommend for or against MRI screening in patients with heterogeneously or extremely dense breast on mammography. There is no family history of breast cancer and there is no history of recent diagnosis of personal breast cancer. For these reasons, this patient does not meet the published criteria for a screening or a diagnostic breast MRI.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested for a bath chair, an automotive positioning device and a portable ramp for treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the patient is unable to be properly supported in a typical car seat.  A bath chair is medically necessary to ensure safety when bathing. This is not a convenience item, as this would not be needed for a child with no medical problems.  A portable ramp is medically necessary since the child does need to be able to enter his home to maintain health and hygiene.  A four-year-old would not normally require a ramp to enter the home, nor would parents typically have to carry a 4-year-old up steps.  An automotive positioning device is medically necessary for safe car transport since the off-the-shelf car seat will not properly position the child.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a four week extension of Harvoni 90/400 mg (from 12 to 16 weeks). Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. This recommendation is based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines do not recommend extending therapy on the basis of detectable viral load at any point. The guidelines state that the significance of a positive hepatitis C viral load result at week 4 that remains positive, but lower, at week 6 or week 8 is unknown. No recommendation to stop therapy or extend therapy can be provided at this time. In cases in which the recommended duration of Harvoni therapy fails as defined by detectable viral load 12 weeks after completion of treatment due to relapse or nonresponse, the guidelines provide specific recommendations to assess for resistance and choose alternative therapies. However, the guidelines do not recommend extension of therapy in this clinical setting.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for applied behavioral analysis (ABA) program evaluation for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the gold standard for establishing the diagnosis of autism is the utilization of the ADOS. However, the ADOS can provide false positives in the clinic setting. More impairment was indicated when a module with more language and task demands was administered. Clinical judgment of the most appropriate module for administration was found to be important. In this case, the patient presents with language delays and inattention. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria listed by the out-of-Plan clinical psychologist was minimally positive. The evaluation performed by the in-Plan developmental-behavioral pediatrician was decidedly negative. The ADOS-2, Module 2 utilized was likely too difficult for this patient given his language delays and inattention. Based on the clinical documentation provided for review, the diagnosis of autism spectrum disorder has not been established. Therefore, the request for an ABA program evaluation is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy and image guided radiation therapy. Findings: The records document that this patient has a history of clinically localized high risk prostate cancer. Current data in the peer-reviewed medical literature and clinical guidelines do not support treatment with proton beam radiation therapy for the treatment of this patients prostate adenocarcinoma. Proton beam radiation therapy has not been demonstrated to yield superior clinical outcomes as compared to intensity modulated radiation therapy (IMRT), with or without a brachytherapy boost, or radical prostatectomy. Moreover, there have been some prospective outcomes reported which have reported an excessive risk for gastrointestinal toxicity associated with proton beam radiotherapy. All told, the requested proton beam radiation therapy and image guided radiation therapy are not medically necessary for treatment of this patient. 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 radiation oncology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services provided on an emergent basis or urgent basis. Findings: The physician reviewer found that the issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with the sudden onset of dizziness and vomiting. He has history of hypercholesterolemia, which is a significant risk factor for atherosclerosis. His blood pressure was elevated on arrival. The combination of these factors placed him at risk for an acute stroke, prompting a CT scan of the brain. Such symptoms may also be characteristic of acute coronary syndrome, despite the absence of chest pain. Therefore, an EKG and cardiac biomarkers were obtained. Given the patients age, sudden onset of dizziness with vomiting and a history of hypercholesterolemia, the services at issue were necessary for an emergency medical condition. Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for methadone. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients pain at this time. The Health Plan advised that the patient taper off the requested medication to a safe dose and talk to their doctor about other medications. The submitted documentation does not support the medical necessity of the requested medication regimen. This patient is being tapered off methadone in accordance with Centers for Disease Control and Prevention (CDC) clinical practice guidelines. A randomized clinical trial conducted revealed that there are several non-opioid medications and physical medicine therapies that can be used to treat patient with multiple types of pain, including chronic back pain. Therefore, methadone is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 anesthesiology with sub-specialty certification in pain 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: Upheld

The patient is a 55-year-old female with chronic pain in the neck, shoulders and back, and chronic headaches. She has requested an MRI and MRA of the shoulders and upper extremities. The patient has previously undergone an MRI and MRA with moderate abnormal findings. The patient is on high-dose narcotics. The Health Plan has denied the requested MRI and MRA and recommended an MRI of the upper chest.The patient has an intractable chronic pain syndrome arising from a work related injury in 1991. The patient has been disabled because of this pain since 1991. The information provided does not demonstrate a significant change in the patients chronic pain indicating the need for a repeat MRI and MRA. The MRI of the upper chest including vascular structures is appropriate and indicated. Therefore, I have determined the requested services are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees antiphospholipid syndrome.  Findings: Two reviewers found that Antiphospholipid syndrome is a serious disorder of abnormal arterial and venous thromboses. Antiphospholipid syndrome is an autoimmune disorder where antibodies are generated against self-antigens that drive the clotting cascade. Some patients have antiphospholipid syndrome and systemic lupus erythematosus whereas others have antiphospholipid syndrome alone. Anticoagulation is the mainstay of therapy, which includes enoxaparin, warfarin, and aspirin. Some studies have suggested that the addition of Plaquenil may be effective in preventing thromboses. All these therapies were tried in this case but the patient still developed clots. Rituxan is a monoclonal antibody directed at CD20, an antigen expressed on B cells. Thus, Rituxan can induce B cell cytopenia and reduction in antibody producing B cells. Rituxan is commonly used in autoimmune disorders based on this mechanism (Gurcan, et al; Rastetter, et al; Zaja, et al). Therefore, Rituxan has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested medication 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 internal medicine with sub-specialty certification in medical oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric services. Per Health and Safety Code Section 1317.1 (a)(2)(A): Emergency services and care also means 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. In addition, Health and Safety Code Section 1317.1 (k)(1) Psychiatric emergency medical condition means a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or to others; (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Based on the documentation provided for review, this patient had a mental disorder that manifested itself by acute symptoms of sufficient severity that it rendered him an immediate danger to himself and others during the period under review. The patient was at serious risk of harm due to impulsivity as demonstrated by his running away and going into abandoned buildings and random cars. In addition, he demonstrated serious functional impairment given his inability to perform in a specialized school setting due to disruptive behavior, which represents an impediment to care for self. Moreover, the patient has severe comorbidities with intellectual impairments that complicate his autism spectrum symptoms and attention-deficit/hyperactivity disorder (ADHD). Given this support, the emergency medical services provided were provided for the treatment of a psychiatric medical emergency. Final Result: The reviewer determined that the services at issue were emergency services as defined by California law.  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.