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

A 72-year-old female enrollee has requested authorization and coverage for computed tomography myelogram of the lumbar spine for evaluation of her lumbar spinal stenosis.  Findings:  The physician reviewer found that patient is not a candidate for the preferred method of evaluation of the lumbar spine with magnetic resonance imaging (MRI) due to the metallic artifacts which would be generated by the hardware. The American College of Radiology (ACR), CT myelogram is the next procedure of choice and is useful when there are contraindications or limitations to MRI.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 14-year-old female with recent onset of headaches, dizziness, photophobia and phonophobia. The history does not suggest seizures. The patients neurologist suggested the patient undergo an MRI and EEG. An MRI was approved, but the Health Plan denied authorization for the requested EEG on the basis it is not medically necessary.There is no role for EEG in the evaluation of headaches or migraines. There is no history suggesting seizure or other neurologic problem that EEG will help to sort out. The recommendation of EEG to assess brain cortical activity does not constitute medical justification for the EEG. There is no clinical indication for EEG in this setting. Therefore, I have determined that the requested EEG is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 17-year-old female who reportedly presented to her provider in crisis. Per the provider, the patient was previously treated with Zoloft for six months. The patient became suicidal and was treated at the partial hospitalization program (PHP) level of care. In September 2017 she was hospitalized with thoughts of harming others. The patient was diagnosed with obsessive compulsive disorder (OCD) and she started medication trials. Due to her presentation, the provider recommended a different therapist who specializes in cognitive behavioral therapy (CBT) for treatment of OCD. Notes indicate the patient prefers Adderall to Vyvanse. Her parent has requested reimbursement for psychiatric emergency services. The Health Plan has denied this request indicating the enrollee did not receive psychiatric emergency medical services. At issue in this case is whether the enrollee received psychiatric emergency medical services on the date(s) 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 available documentation reports the patient underwent medication changes while in treatment. However, the notes do not describe any symptoms that were emergency related. The patient has OCD symptoms and her medications were being adjusted to address these symptoms. There is no indication that the patient was experiencing suicidal or homicidal ideation or aggression. There is no indication that the patient was experiencing psychosis. These symptoms are typically considered emergencies in psychiatric care (case study). There was no indication of dangerous symptoms that would require inpatient psychiatric acute-care for this patient. It does not appear that there any documented symptoms that were in need of treatment on an emergent basis. Thus, the services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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

A 20-year-old female enrollee has requested authorization and coverage for a spinal disc add-on (arthroplasty) of L5-S1 and fusion of L4-L5 surgical procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees L5-S1 and L4-5 degenerative disc disease and lumbar radiculopathy.  Findings:  Three physician reviewers found that this patient has chronic low back pain. There is no evidence of any localizing features to her pain and the records do not demonstrate that either L4-5 or L5-S1 have been determined to be her pain generators. Additionally, there is no evidence provided that the patient has any instability, spondylolisthesis, infection or scoliosis, which are accepted criteria for lumbar fusion (Milliman Care Guidelines; Bambakidis, et al.). The use of an artificial disc is considered experimental/investigational, as there is a lack of large, scientific studies establishing its long term safety and efficacy. Additionally, the Food and Drug Administration (FDA) has required a five, seven and ten year study regarding the long term safety and efficacy of total disc replacement, which is still ongoing. In sum, the available peer reviewed medical literature and the medical records provided do not demonstrate that the requested lumbar fusion and artificial disc replacement procedure is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 60-year-old female enrollee has requested authorization and coverage for L4-5 and L5-S1 facet joint nerve (FJN) block. In the documentation available for review, the provider did not document examination findings consistent with facet arthropathy at all of the levels requested for treatment (case study). In addition, the patient is likely to obtain the same relief from a steroid injection alone without also having the increased risk from a radiofrequency ablation procedure (case study). All told, the medical records do not support the requested procedure in this clinical setting. Therefore, the requested authorization and coverage for L4-5 and L5-S1 facet joint nerve (FJN) block, are not medically necessary for treatment of 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 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: Overturned

A 55-year-old male enrollee has requested for residential treatment services for treatment of his alcoholism. Findings:  The physician reviewer found that given the patients prodigious drinking, family history of severe alcohol dependence, having quit his job and being isolated, alongside an inability to really remain sober for any sizable period of time, a more protected and intensive treatment appears to have been in order.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain. Findings:  The physician reviewer found that relevant literature fails to demonstrate the medical necessity of the requested diagnostic study. The patient presents with low back pain, which radiates to the left hip. The patient is also status post lumbar decompression at L5-S1. The medical records submitted for review provides no documentation on physical examination of the presence of or progression of neurological deficits. In addition, the journal article by Thavarajah and colleagues indicates that repeat MRI scanning does not alter the surgical target site; and therefore does not change management. Furthermore, there is no indication as to whether the patient is being considered for possible surgery, thus the request for a repeat MRI of the lumbar spine has not been established. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic study is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old female seeking abdominoplasty for a hanging panniculus post gastric bypass, which apparently was performed in 1986. The patients stated weight is 151 pounds and her height is 60 indicating a body mass index of greater than 30. This suggests that the patients weight loss surgery has failed. The Health Plan has denied coverage for an abdominoplasty on the basis that it is not medically necessary. Review of the examination records of the plastic surgeon and the patients photographs demonstrate an obese female with a double pannus. Thus, it does not appear the patient has a true hanging pannus. Furthermore, although there is patient derived history of intertrigo, there is no clinical evidence of the same. Thus, there is insufficient evidence that an abdominoplasty is medically indicated. As such, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested a panniculectomy for treatment of her overlapping abdominal pannus.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested surgery.  The patients functional issues have been noted to have been present for several months. The patient has failed conservative management of antibiotic treatment and local surgery for cyst removal. The overhanging pannus is likely contributing to the chronic open wound and history of infected cyst. Therefore, a panniculectomy would likely address this functional deficit and is medically necessary for treatment of the patients medical condition.  With regard to whether the proposed procedure meets reconstructive surgery criteria, the patient presents with a severely overlapping abdominal pannus with apparent active intertrigo. The patients chronic wounds may be associated with infection in which the severe pannus is a likely contributing factor. The requested surgery is being performed to improve function. The patient has had multiple chronic conditions associated with her severely overlapping abdominal pannus and has failed reasonable conservative management of wound care, local surgical correction of a chronically infected cyst and medical management. The requested panniculectomy would likely address the functional deficit. Although the requested panniculectomy would offer a significant improvement in the appearance of the patient, this is not the primary goal. The patient has a functional deficit related to the severe pannus. The submitted documentation shows that this patient has a severely overlapping abdominal pannus that is likely significantly contributing to her functional deficit of poor healing and chronic infection. Therefore, the requested surgery does meet the reconstructive surgery criteria.  Final Result: The reviewer determined that the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg every four weeks. The current medical literature supports dose escalation of Stelara in this case. A large randomized controlled trial demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohns disease which was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. The study showed a 73.7% response rate in patients with anti-TNF-resistant Crohns disease. A significant majority of these patients were able to discontinue steroids. The current medical evidence supports the requested medication dosage in this patients case. Alternative therapies are limited, as the patient has failed treatment with other biologic therapy for Crohns disease. For these reasons, Stelara 90 mg every four weeks is medically necessary for the treatment of this patients Crohns disease.Final Result: The reviewer determined that the requested medication dosage 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 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: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested for Electron Beam Computed Tomography (EBCT) for evaluation of his coronary condition.   Findings:  Three physician reviewers found that Electron Beam Computerized Tomography (EBCT) is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and it is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. The use of this test in the diagnosis and prognosis of coronary disease in this subset currently remains an experimental/investigational application of this technology.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested dermatology services for treatment of her scalp lesion. Findings:  The physician reviewer found that the patient presents with a history of basal cell carcinoma and is requesting dermatology services related to a scalp lesion. The patient complains of blisters on the skin which could be an indication of an autoimmune blistering disorder, such as pemphigus vulgaris of bullous pemphigoid. Additionally, the patient has a history of basal cell carcinoma, which in and of itself, is an indication for routine dermatology evaluation as yearly skin exams are recommended for those with a history of skin cancer. Given the potential for a serious skin disease such as pemphigus vulgaris, bullous pemphigoid, or bullous impetigo and history of skin cancer, the request for dermatology services is medically necessary.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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HP Acthar Vial. Acthar Gel, an adrenocorticotropic hormone (ACTH) analogue, is U.S. Food and Drug Administration approved for treatment of symptomatic sarcoidosis at a recommended dose of 40-80 units intramusculary or subcutaneously every 24-72 hours. Sarcoidosis is a systemic granulomatous disease of unknown etiology. Over the past few years, there have been advances in understanding of sarcoidosis. These include observations about the etiopathogenesis, diagnosis, and treatment of the disease. The first-line treatment is recommended to be glucocorticosteroids. However, the patient has tried and failed these options without success. In addition, the patient is diabetic and long-term use of steroids is not recommended. According to the peer-reviewed medical literature, repository corticotropin treatment, or Acthar, is prednisone sparring and has shown to have associated improvement in diffusing capacity of the lung for carbon monoxide (DLCO), positron emission tomography (PET) scan, and patient-reported outcome measures with sarcoidosis. Acthar has been shown to stimulate the melanocortin receptors (MCRs), which have anti-inflammatory activities. Although there is a risk with toxicity, the treatment has proven to be an effective treatment for patients with sarcoidosis. It was noted that the patient has tried and failed prior treatments and it is reasonable and appropriate for the patient to undergo Acthar gel treatment at this time. Given the above, the request for HP Acthar Vial is medically necessary for treatment of the patients medical condition. 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 pulmonary 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: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that gastric bypass with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for applied behavior analysis (ABA) services. Per the ABA Coding Coalition treatment plan guidelines, ABA services are medically necessary when supported by adequate documentation including proposed treatment targets, goals, and objectives. This patients records do not include a thorough treatment plan and this information was not reported in the patients medical records. The patients diagnostic report did not recommend ABA, rather, the provider endorsed parent training, individual therapy, family therapy, and assistance in the school setting. The Centers for Disease Control and Prevention (CDC) guidelines support the use of parent training in behavior management, behavioral classroom management, and medication for young patients with attention-deficit/hyperactivity disorder (ADHD). In addition, the recommended treatment for oppositional defiant disorder (ODD) includes include individual therapy, family therapy, social skills training, and medication. The current medical literature and guidelines do not recommend ABA as an effective treatment modality for patients with ODD. Moreover, the requested ABA services fail to meet the medical necessity criteria. Researchers noted, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on these criteria, the patient fails to meet criteria (b) and (c). There is lack of evidence that ABA is an appropriate treatment for this patients ADHD or ODD, and the type, frequency and duration of treatment cannot be assessed without a current treatment plan. For these reasons, the requested ABA services are not medically necessary for 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 a licensed B.C.B.A, board certified in psychology, 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.