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

A 42-year-old female enrollee has requested Phenergan injections and hydromorphone with Dilaudid for treatment of her migraines.  Findings:  The physician reviewer found that there are many prophylactic migraine treatments that are available to treat migraine.  There are several new techniques with trigger point injections. Phenergan and Dilaudid injections are not part of routine care and provide only very short-term relief, with no long-term benefit.  There are oral dissolvable 5-HT receptor agonists, injectable triptans and oral dissolvable triptans that offer superior efficacy and less addictive alternatives for migraine treatment, with better long-term outcomes.  In truly refractory cases, referral to a headache center with comprehensive services that offer psychological, pharmacological, and physiologically appropriate regimens including injection therapy are more beneficial for long-term help in migraine conditions.  All told, the requested Phenergan injections and hydromorphone with Dilaudid are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Levemir FlexTouch 100 unit/mL (3 mL). The patient has been diagnosed with type 1 diabetes mellitus.Researchers reported that all insulins have the same mechanism of action on target tissues (i.e., all insulins have the same action if administered intravenously). Therefore, the different timeaction profiles of various insulins result from differences in their behavior in the subcutaneous space, which then affects the rate of absorption into the circulation. The Health Plan noted that Levemir may be approved where there is an inadequate response to intolerance to Basaglar. In this case, the patient has responded well to Levemir insulin and has had suboptimal control on Basaglar. The medical evidence supports the requested medication in this clinical setting. Therefore, Levemir FlexTouch 100 unit/mL (3 mL) is 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 internal medicine with sub-specialty certification in endocrinology and metabolism 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 66-year-old male requested authorization and coverage for an MRI of his back.  The Independent Medical Review determined that the service desired was not medically necessary.  Thus, the health plan is not required to provide this service.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for neuropsychological consultation for evaluation of the enrollee's behavioral health condition.Findings: The physician reviewer found that the request for a neuropsychological consultation is not medically necessary for evaluation of the patients medical condition. In this case, the patient has difficulty communicating effectively, with limited insight and self-reflection. For patients with low functioning ASD, behavioral therapy is recommended, which this patient is receiving along with in-home ABA. In general, neuropsychological consultations are utilized when there is a diagnostic issue. The record does not demonstrate that the patients diagnosis is at issue. The documentation submitted for review includes progress reports with scales and measurements that are typically performed during a neuropsychological consultation. The patients social skills, language, emotions, and attention are measured and monitored which is similar to what a neuropsychological assessment would entail. Therefore, a neuropsychological consultation is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is 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 psychiatry with sub-specialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cxbladder urine testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that  Cxbladder urine testing was not likely to be more effective for this patient than other available options. Cxbladder may eventually have a role in defining clinical outcome in known bladder cancer, however at this time there is a lack of evidence in the peer-reviewed literature supporting its use. Moreover, there is a lack of support for the use of Cxbladder in the clinical setting of known BPH, negative urinalysis, and negative risk factors for bladder cancer. All told, the Cxbladder performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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:   All three reviewers are board certified in urology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services on an emergent basis. Findings:  The physician reviewer found that The surgical services were not necessary for treatment of an emergency medical condition. The patient had a diagnosis of a weak nickel allergy after placement of Essure implants. Allergic contact dermatitis from nickel hypersensitivity is a type IV reaction, also known as delayed-type hypersensitivity, which results in cell-mediated T-cell activity. Common manifestations of contact allergic reactions are contact hypersensitivity, such as eczema, generalized dermatitis, and urticaria. In this case, the patient underwent laparoscopic removal of the Essure implants. There is a lack of evidence in the medical record demonstrating that the patient was in acute distress prior to the laparoscopic procedure. In addition, there is a lack of evidence showing that medical screening, examination, and evaluation was required to determine if an emergency medical condition existed and that surgery was necessary to eliminate an emergency medical condition. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 20-year-old female enrollee has requested residential substance abuse treatment for treatment of her opiate dependence. Findings:  The physician reviewer found that in this patients case, the requested residential substance abuse treatment is not medically necessary. The patient has not attempted and failed a less restrictive setting, such as intensive outpatient or partial hospitalization program.  At this juncture, residential treatment is not in accordance with accepted standards of practice. The submitted notes reflect precontemplation/contemplation stages of change. However, no action has been taken to date despite viable options, such as opiate agonist treatment with Suboxone. The patients reported symptoms of depression and anxiety have not been formally diagnosed and treated.  Treatment for depression and anxiety has been shown to improve outcomes for substance use disorders.  This treatment can be offered at a lower level of care, as there is no documentation of active suicide risk requiring 24-hour supervision under a physicians care. This patient does not have significant comorbidities that would preclude her from successfully engaging in outpatient treatment. Given that the patient has not actively engaged in comprehensive outpatient treatment, including office-based opiate agonist substitution, residential treatment is not likely to affect her clinical status at this time. All told, the requested residential substance abuse treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of a PET scan. The Health Plan denied the request indicating that the requested PET scan is not medically necessary for evaluation of the enrollees endometrial carcinoma with extension to the fallopian tube.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested PET scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acromioplasty for the authorized right shoulder repair surgery. The records document that this patient is being treated for right shoulder primary osteoarthritis and biceps tenosynovitis as well as a small right shoulder rotator cuff tear. Physical examination of the right shoulder revealed tenderness to supraspinatus footprint and bicipital groove, and mild tenderness to the acromioclavicular joint. The records indicate that Hawkins, Neers, and Speeds tests were positive. The patient has undergone adequate attempts at conservative treatment modalities as documented in the providers notes. The addition of the recommended acromioplasty is supported as appropriate for this patient based on the current medical literature given the evidence of subacromial bursitis/subacromial impingement that has been refractory to conservative measures. Medical literatures reported that acromioplasty is a good surgical option for the treatment of shoulder impingement with an intact rotator cuff. All told, the requested acromioplasty for the authorized right shoulder repair surgery 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 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 parent of a four-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that, as noted by and Pickett and colleagues, early studies of patients with autistic spectrum disorder (ASD) initially reported a poor prognosis for the future development of speech in nonverbal patients, but there is newer evidence that these patients may develop useful speech with appropriate therapy. In regards to the medical necessity of speech therapy services for the treatment of this patient, laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with ASD. At issue is the notion that plasticity in the developing brain still exists, even in individuals with underlying neurologic disease, and can be utilized to improve overall neurologic health. Thus, specific treatment including speech therapy in an individualized setting is clinically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested acute inpatient hospital detoxification  for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the services at issue. Based on the patients lengthy history of heavy alcohol consumption on a daily basis, this patient was at high risk for complicated alcohol withdrawal. Upon presentation, the patient had a slightly elevated systolic blood pressure and normal pulse.  In addition, the patients most recent drink was earlier that day and she was also taking two antihypertensive medications. A diazepam taper was promptly started at the time of hospitalization. Thus, her withdrawal syndrome was effectively treated very early on and did not result in autonomic instability. The patient had several other factors that supported a conservative treatment approach. For example, the patients drinking resulted in blackouts and withdrawal symptoms and she was unable to achieve sobriety in a less restrictive setting. Further, she had a concerning family history that included the substance-related death of a sibling. Finally, she was burdened by significant psychosocial stressors and a co-occurring mood disorder. Given the patients clinical presentation coupled with the need to prevent a more serious health condition, medically supervised detoxification in a 24-hour setting was safe, appropriate and consistent with good medical practice.  Thus, the acute inpatient hospital detoxification services provided during the time frame specified were medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested removal of the titanium clips that were placed during her previous cholecystectomy; and abdominoplasty with high incision to resect a scar on her right flank; and advance retail and redistribution of large scar tissue in the right thigh for treatment of her medical condition. Findings:  The physician reviewer found that the request to remove titanium clips that were placed during the patients previous cholecystectomy is not medically necessary. Although hypersensitivity to titanium dental and orthopedic implants has been reported, there is a lack of medical literature that reports allergies or hypersensitivity to an intra-abdominal titanium clip following a cholecystectomy (Stejskal, et al). Moreover, the risk of clip removal far outweighs the benefit. The request for abdominoplasty with high incision to resect a scar on the patients right flank is not medically necessary for treatment of the patients medical condition. Abdominoplasty has not been demonstrated to be an effective treatment for hip or thigh pain (Staalesen, et al). The request for advance retail and redistribution of large scar tissue in the right thigh is not medically necessary in this clinical setting. The medical records do not document the presence of a functional impairment that is likely to be improved by the proposed procedure. Further, based upon the submitted documentation, the patients condition does not meet criteria for reconstructive surgery. All told, the requested procedure is not medically necessary or reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xultophy. The submitted documentation does not support that the requested medication is medically necessary. Xultophy is a combination of Tresiba (Deglutec) and Liraglutide. In this case, the patient had intolerance to Metformin therapy and intolerance to Levemir insulin. There is no documentation of his current hemoglobin A1c results. The submitted documentation does not reflect that the patient has tried and failed other treatment options including non-metformin first-line oral diabetic agents, and basal insulins other than Levemir and GLP-1 agents, prior to being started on the requested medication. A trial of such step therapy alternatives would be consistent with the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) Comprehensive Type 2 Diabetes Management Algorithm. Accordingly, the requested for Xultophy is not medically necessary for treatment of the patient's 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 internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism. 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy services. Findings:  The physician reviewer found that the patient has had chronic symptoms affecting the upper limbs, with no clearly demonstrated pathology or etiology. Evaluations at her primary care provider's office have been incomplete, with no documentation of an examination of the limbs. The reported diagnoses appear to be based on subjective complaints. A workup with neurology was reported to have no significant findings. The records indicate the patient reported being told that she had arthritis. Physical therapy, in this case, has focused on the administration of passive interventions such as manual therapy and ultrasound. These interventions provided no proven health or functional benefit in the setting of this clinical scenario.  There is no expectation of marginal benefit of ongoing formal physical therapy in this case above what would be achieved with a compliantly followed exercise, stretching and self-applied palliative modality program. There are no objective physical examination findings to support continued treatment with physical therapy. There were no significant findings reported by neurology. Therefore, the requested physical therapy is not medically necessary to treat the patients medical condition.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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for office visits (99204 x 4) and electrolysis services (17380 x 96). Findings:  The physician reviewer found that Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Coleman and colleagues authored standards of care that lists hair removal through electrolysis, laser treatment, or waxing as a standard treatment to alleviate gender dysphoria. Additionally, the World Professional Association for Transgender Health (WPATH) supports facial hair removal and gender affirming counseling or psychotherapeutic treatment for the treatment of patients with gender dysphoria. In this case, the patient has been diagnosed with gender dysphoria. Moreover, the patient desires to have hair removed in areas visible to others in order to conform to her chosen gender role. There is sufficient support for the requested services in this clinical setting. Therefore, office visits (99204 x 4) and electrolysis services (17380 x 96) are medically necessary to treat the patients medical condition as defined in Health and Safety Code section 1374(a)(3)(A). Specifically, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. The requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. Additionally, the requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition as defined in Health and Safety Code section 1374(a)(3)(A). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in transgender 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

A 19-year-old female enrollee has requested scar excision/revision for the treatment of her keloid. Findings:  The physician reviewer found that the submitted documentation does not support the presence of an abnormal structure of the body in the patient caused by congenital defects, developmental abnormalities, infection, trauma, tumor or disease. The submitted medical record documentation does not demonstrate that the excess tissue is so great so as to be considered abnormal. The keloid would have to be quite large to be considered an abnormal structure. Thus, the California statute regarding reconstructive surgery does not apply. With regard to general concepts of medical necessity, the presence of a keloid scar in and of itself does not make its removal medically necessary. It must be established that the procedure is necessary to improve functional impairment or relieve symptoms caused by the keloid. In the absence of objective, medical chart documentation of impaired function, such as blockage of the ear canal or impaired range of motion, and/or symptoms, such as pain, itching or infection, the proposed removal of the patients keloid scar is not necessary from a medical standpoint.