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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy services. Findings:  The physician reviewer found that Proton therapy can result in more conformal dose distribution with less low dose spillage versus standard three-dimensional conformal radiation therapy (3DCRT) or intensity modulated radiation therapy (IMRT). However, there is a paucity of studies directly comparing the health outcomes and risks associated with proton versus photon palliative radiation therapy. In this patients clinical setting, palliative radiation is routinely performed with photons via simple, 3DCRT, and IMRT techniques with excellent response. On review of this patients records, the recommended dose is well below the tolerance of adjacent normal tissue. Treatment with photons would not exceed the appropriate dose limits to the heart or spinal cord. Moreover, given the beam arrangement of the provided proton plan, there was no significant improvement in the spinal cord dose-volume-histogram plan versus the photon plan. In addition, the American College of Radiology (ACR) does not support treatment with proton beam therapy for this patients metastatic breast cancer (Lo, et al.). The authors noted that, The treatment of spinal bone metastases depends on histology, site of disease, extent of epidural disease, extent of metastases elsewhere, and neurologic status. On review of this patients clinical presentation, current medical literature and ACR guidelines, as well as the provided comparative planned dose-volume-histogram of photon versus protons do not support an indication for treatment with proton beam radiation in lieu of standard 3DCRT or IMRT. Therefore, the proton beam therapy services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for sacroiliac joint fusion surgery. As noted in the medical literature, sacroiliac joint block is the gold standard to establish a diagnosis of sacroiliac joint dysfunction (Zaidi, et al.). Simopoulos and colleagues performed a systematic evaluation of sacroiliac joint interventions. The authors commented that, The diagnosis and treatment of sacroiliac joint pain continues to be characterized by wide variability and a paucity of the literature. The authors concluded that, Based on present knowledge, a proper diagnosis can only be made using controlled diagnostic blocks. This patients records do not include documentation of response to sacroiliac joint block injections. In this clinical setting, SI fusion is not anticipated to produce a positive result. Therefore, the sacroiliac joint fusion surgery was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for computed tomography (CT)-guided microwave ablation left hepatic lobe mass with anesthesia. Findings:  Three physician reviewer found that the request for CT-guided microwave ablation left hepatic lobe mass with anesthesia is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical records fail to indicate that this patient is not a candidate for additional chemotherapy or radiation. In addition, there is a lack of peer-reviewed evidence that microwave ablation of this patients left hepatic mass will provide a better clinical health outcome that available standard therapies of surgical resection or additional chemotherapy and radiation. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in interventional radiology and diagnostic radiology and is actively practicing. Physician reviewers number two and number three are board certified in radiation 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for behavioral health residential treatment care (RTC) services.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient reported that he did not have suicidal or homicidal thoughts. The provided records did not indicate that the patient had history of any suicide attempts. The patient had not attended a partial hospitalization program (PHP) or an intensive outpatient program prior to his admission to the RTC. The patients parents were supportive of the patient. The patient participated in treatment. The patient did not have psychotic symptoms. The patient did not have medical problems, which would require 24 hour supervision.  It is standard of care to treat all patients in the least restrictive environment as possible. It does not appear that this patient required 24 hour supervision. The patient did require treatment, but based on the records, this patient could have been treated at a lower level of care in a PHP setting with daily psychotherapy integrated with medication management. Therefore, behavioral health residential treatment care services were not medically necessary.  Final Result: The reviewer determined that the requested name brand 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 psychiatry with expertise 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: Overturned

The parent of a three-year-old male enrollee has requested speech therapy services and occupational therapy services for feeding therapy, activities of daily living deficits and sensory-motor proprioceptive impairments for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that both the speech and occupational therapists have recommended continued therapy. The above references deal with the effectiveness of OT sensory-motor techniques for children. Schaff, et al. documents the effectiveness of sensory integration therapy by occupational therapists for children with multiple combinations of developmental sensory and motor delays. Miller, et al. involved a controlled study of the effectiveness of sensory motor therapy in a childhood population. Dramatic improvements in behavior and attention were noted when patients received occupational therapy utilizing sensory motor techniques (Roberts, et al.). Children with speech delay can be readily treated (Law, et al.), and speech-delayed children, such as this patient, are ideal candidates for successful speech therapy (Goorhuis-Brower and Kniff).  The medical community standard is to offer both speech and occupational therapy to children with this degree of speech and developmental delay. All told, the requested therapies are medically appropriate and indicated to address this patients severe expressive language delay, feeding issues, deficiencies in activities of daily living and sensory-motor proprioceptive impairments Therefore, the requested services are medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance transportation services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services. 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 ambulance transportation services provided were necessary for treatment of an emergency medical condition. In this case, the patient experienced the sudden onset of headache and dizziness while driving. He was driving erratically, of which he was unaware, when he was pulled over by the highway patrol. The highway patrol called 911. The paramedics found the patient to be tachycardic. He was administered an antiemetic and an EKG was obtained. In the emergency department, the patient was evaluated for a brain hemorrhage as well as acute coronary syndrome. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a cervical discography (CPT 62291, 62291-59 and 72285-26).Findings:  The physician reviewer found that Findings:  Three of the three physician reviewers found the cervical discography (CPT 62291, 62291-59 and 72285-26) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Current medical literature does not clearly show that cervical discography is superior to conventional treatment. Onyewu and colleagues, as well as Manchikanti and colleagues, note that literature on cervical level discography is limited at best, with contradictory and variable evidence for the procedure. DeFrancesch and colleagues report that one of the problems with discography is that the results rely heavily on patient experience of the pain produced by the procedure. Therefore, the cervical discography (CPT 62291, 62291-59 and 72285-26) was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapyFinal Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment 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 orthopedic surgery 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: Upheld

A 47-year-old male enrollee has requested for a computerized tomography (CT) scan of the chest for evaluation of his left lung nodule. Findings:  The physician reviewer found that the Fleischner Society has published guidelines for evaluation and follow-up of a solitary pulmonary nodule incidentally identified on a CT scan. For pulmonary nodules that measure 4 mm or less in size, no further follow-up imaging is indicated if the patient is a non-smoker and has no other risk factors. For pulmonary nodules that measure 4 mm or less in size in a patient with a significant history of tobacco use or other risk factors, including a family history of lung cancer, a follow-up unenhanced CT of the chest is recommended 12 months following the initial study. These guidelines are accepted and utilized by the medical community. This patient was noted to have a solitary pulmonary nodule within the left lower lobe measuring 3 to 4 millimeters on a CT scan. Using the guidelines of the Fleischner Society, a follow-up CT scan of the chest would be appropriate 12 months following the initial CT study. Therefore, the CT scan of the chest that was requested six months following the initial CT study is not medically necessary or indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old male enrollee has requested for continued intensive outpatient program services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that three hours per week of intensive outpatient program services is medically indicated for this patient.  This will allow treatment for social skills training, individual therapy and family therapy with his mother.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The records provided for review document that this patient has failed multiple therapies including conventional therapy and high-dose Entyvio, which are recommended for the treatment of ulcerative colitis (Rubin, et al.; Sands, et al.). Subsequently, the patient experienced good results with Stelara every eight weeks, with return of symptoms and a low trough level. The provider has recommended treatment with Stelara every four weeks. Stelara has been demonstrated to be safe and effective in the treatment of ulcerative colitis. Recent studies have demonstrated that Stelara 90 mg every four weeks is safe and well-tolerated for the treatment of inflammatory bowel disease, with recovery of effectiveness in patients with active disease (Kopylov, et al.; Battat, et al.; Khorrami, et al.). One recent study showed that 43% of patients with ulcerative colitis on Stelara required dose escalation, and over 50% of patients with dose escalation achieved corticosteroid-free remission, and long-term improvement in endoscopic inflammation (Dalal, et al.). In this case, the patient has moderate-to-severe ulcerative colitis. The records document that the patient has failed multiple recommended alternatives, has a low Stelara level when dosed every eight weeks, complains of active disease symptoms, and has an elevated fecal calprotectin. As the patient experienced initial improvement on Stelara, but a low Stelara level, dose increase to Stelara 90 mg every four weeks is supported. Continuation of the current dose of  90 mg every eight weeks or a change to another medication may be ineffective and may result in complications. For these reasons, the requested Stelara 90 mg every four weeks is supported as medically necessary for the treatment of this patient. 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 subspecialty 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

The patient is a 51-year-old morbidly obese female who underwent simultaneous gastric bypass and panniculectomy.  She subsequently underwent revision of the panniculectomy scar and excision of thigh skin with suction assisted lumpectomies (thighplasties). The patients postoperative course was marred by the anticipated cellulitis of the right thigh. Because of persistent bulging of the thighs and lateral trunk, the patients plastic surgeon has requested authorization for liposuction of these areas. The Health Plan has denied authorization for the requested procedure on the basis it is cosmetic in nature and therefore, not medically necessary.The submitted medical records and photographs do not demonstrate medical necessity for suction assisted lipectomy of the legs and chest. There is insufficient objective evidence of a functional impairment resulting from the patients excess skin. The requested procedure is cosmetic in nature and is not medically indicated. Therefore, I have determined 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: The patient has requested authorization and coverage for 35 additional days of residential therapy treatment services for treatment of the enrollees obsessive compulsive disorder (OCD), major depressive disorder, recurrent, severe, without psychotic features, and attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that In accordance with modern psychiatric practice, the records document that this patient has pursued treatments in less restrictive treatment settings other than residential level of care. She began with outpatient services and was stepped up to PHP. Despite the higher level of care and complex pharmacotherapy, the patient remained symptomatic with an illness burden that was negatively impacting all functional domains. Thus, her providers recommended residential placement. Such progression in level of care is consistent with the recommendations from the American Psychiatric Association (APA). The APA noted that, residential treatment may be indicated in individuals with severe treatment-resistant OCD, who require multidisciplinary treatment in a highly structured setting that permits intensive individual and group CBT [cognitive behavioral therapy] as well as psychopharmacologic management with close monitoring of treatment adherence over a period of several months. In sum, the patient has a history of mental illness dating back to childhood. She has multiple psychiatric diagnoses and a formidable symptom complex that has included suicidal behavior. She has failed less restrictive treatment settings during the episode of illness. She is motivated for recovery and is actively engaged in evidence based treatment. The setting and services in dispute are consistent with contemporary psychiatric practice, and are reasonably expected to both improve her condition and prevent a more serious episode of illness. However, based on the clinical documentation, the specific request for 35 days of additional treatment is not supported as medically necessary. Typically, an initial 30-day residential admission would be consistent with community standards in a case such as this. For these reasons, residential therapy treatment services are medically necessary through 12/15/17 for treatment of the patients medical condition, but not thereafter. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.