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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for all or any of the mental health RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of hospitalization for suicidality, multiple past impulsive suicide attempts, and incidents of self-harm.In terms of functional status, the records support a score of 4. The documentation noted significant functional impairment due to withdrawal and avoidance of almost all social interaction. The patient rarely left her room, isolated from friends, and missed half to 80% of her school year. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of dyslexia, attention deficit disorder, and Tourettes syndrome.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to disruptions caused by the pandemic, and her mothers recent marriage. With regard to level of support of the recovery environment, the records support a score of 3 due to her mothers inconsistent attendance at family therapy sessions. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment. With regard to treatment acceptance and engagement of the parent, the records support a score of 3. The patients mother was incompletely engaged, due to her inconsistent attendance of family therapy sessions and lack of response to phone calls and emails from the residential treatment center staff. Thus, the patient has a total score of 21. The records support a score of 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received at the residential treatment center. Therefore, mental health RTC services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for social skills group therapy and group speech therapy services. Findings:  The physician reviewer found that based on the available documentation, the social skills group therapy and group speech therapy services provided were not and are not medically necessary for treatment of this patients medical condition. The National Autism Center highlights ABA therapy as the most effective evidence-based treatment for autism. In this case, the patient is currently accessing medically necessary treatment in the form of ABA therapy, which has led to a decrease in overall autism symptoms. While the patient still has specific areas of concern, his ABA provider has outlined goals to focus on the patients specific deficits. Further, the patients speech and language assessment from 3/12/18 indicated that the patient should wait until five years of age for social skills group, and social goals should continue to be addressed through ABA services. All told, the social skills group therapy and group speech therapy services provided were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 psychology and is a board certified behavioral analyst 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 Ambien (zolpidem tartrate) 10 mg for treatment of the enrollees insomnia. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The U.S. Food and Drug Administration (FDA) has approved the use of Ambien for short-term treatment of insomnia with difficulty of sleep onset.  Ambien is not approved for the long-term treatment of insomnia.   When treating insomnia, patients should receive therapy for any medical condition, psychiatric illness, or sleep disorder that may be precipitating or exacerbating the insomnia.  For patients who continue to have insomnia that is severe enough to require intervention, cognitive behavioral therapy (CBT) is the initial therapy that is recommended.  If a patient requires a combination of behavioral therapy and medication, a short-acting medication is recommended for six to eight weeks and then tapered.  In this case, the documentation does not support that the patient has received optimal therapy for medical and psychiatric conditions or that non-pharmacologic treatment for insomnia has failed.  There is a lack of support for the requested medication in this clinical setting.  Therefore, the requested medication is not medically indicated for the treatment of this patient.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 physician reviewer is board certified in internal 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

A 48-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for the treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a magnetic resonance imaging (MRI) of the spine and hip without dye for medical evaluation of her back and hip pain. Findings:  The physician reviewer found that based on the records provided, this patient has no red flags to mandate advanced imaging without first undergoing an adequate course of physical therapy. Moreover, there are no contraindications in the records provided for a conservative course of management prior to consideration for additional imaging with MRI of the spine and hip. For these reasons, the requested MRI of the spine and hip without dye is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested speech therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient was not diagnosed with autistic spectrum until the age of 11, which would imply relatively mild communication defects. Testing indicated relatively mild communication defects.  When retested, nearly all of his communication skills were in the normal range. The progress notes demonstrate that the emphasis was not on actual communication skills, but emphasized organizational efforts and intellectualizing skills (i.e., what to say and the way to say it). The emphasis was on a process to improve intellectual processing of language, rather than focusing on receptive or expressive language (i.e., not speaking, but prethinking what to say and organizing thoughts). Thus, the speech therapy rendered was not medically necessary for treatment of the patients condition. Furthermore, since the patients expressive and receptive language is in the normal range, additional speech therapy is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees hepatitis C. 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Upheld

A 35-year-old male enrollee has requested endoscopic piriformis release surgery for treatment of the enrollees piriformis syndrome.  Findings:  The physician reviewer found that this patient presents with chronic pain. However, his pain generator has not been identified. He has normal neurologic and orthopedic examinations and there is a lack of documentation by examination to substantiate a diagnosis of piriformis syndrome. In addition, the patient has not reportedly received substantial relief after piriformis injection. In the medical literature, Filler noted that before surgery is considered, two successful blocks should have been received. Further, there are no large, prospective, scientific studies that have shown the efficacy of this surgery. Only small, retrospective studies are reported (Benson and Schutzer). There is no large body of literature that supports the diagnosis of piriformis syndrome. Campbell and Landau noted that, there is little definite evidence in the literature to support the diagnosis of piriformis syndrome. Miller and colleagues noted that, diagnosis is hampered by lack of agreed upon clinical criteria and lack of definitive investigation such as imaging or electrodiagnostic studies. Thus, any surgery on this patients sciatic nerve for piriformis syndrome is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for consultation with an endocrinologist.Singhi and Saini stated that syncope is not a disease in itself but a symptom of an underlying disorder; hence, children with syncope require assessment to exclude an underlying life-threatening cardiac or non-cardiac disorder. Syncope describes a sudden and brief transient loss of consciousness (TLOC) with postural failure due to cerebral global hypoperfusion. The term TLOC is used when the cause is either unrelated to cerebral hypoperfusion or is unknown. According to Bassetti, the most common causes of syncopal TLOC include cardiogenic syncope (cardiac arrhythmias, structural cardiac diseases, others), orthostatic hypotension (due to drugs, hypovolemia, primary or secondary autonomic failure, others), and neurally mediated syncope (cardioinhibitory, vasodepressor, and mixed forms). Rarely, neurologic disorders (such as epilepsy, transient ischemic attacks, and the subclavian steal syndrome) can lead to cerebral hypoperfusion and syncope. Non-syncopal TLOC may be due to neurologic (epilepsy, sleep attacks, and other states with fluctuating vigilance), medical (hypoglycemia, drugs), psychiatric, or post-traumatic disorders. In this case, the patient has had two syncopal episodes that are possible of non-cardiac origin per cardiology evaluation. The patient has been evaluated by multiple specialists for different problems. He does not have diabetes. However, the diagnosis of hypoglycemia as a cause of syncope has not been ruled out. An endocrinology evaluation to rule out reactive hypoglycemia as a cause of syncope and pre-syncopal symptoms is reasonable. Therefore, the requested consultation with an endocrinologist is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for the 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 endocrinology, diabetes, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz oral tablets 5 mg. Current medical literature supports the safety and efficacy of tofacitinib (brand name Xeljanz) in treating severe alopecia areata. Tofacitinib, a systemic medication often prescribed to patients with rheumatoid arthritis, has been documented to result in clinical improvements in patients with alopecia areata. Researchers concluded that based on a retrospective study of patients aged 18 years or older with alopecia areata, with at least 40% scalp hair loss, tofacitinib should be considered for the treatment of severe alopecia areata, alopecia totalis, and alopecia universalis. Researchers report that Janus kinase (JAK) inhibitors, such as tofacitinib, are a therapeutic option that is safe and effective for the treatment of severe alopecia areata. Researchers make the definitive statement that JAK inhibitors are the ideal choice of systemic therapy in adults. In this case, the patients alopecia areata is not controlled by standard steroid or calcineurin inhibitor regimens. Her symptoms have progressed to eyelash loss, which may negatively affect her vision due to an increased risk of eye irritation. In this clinical setting, given that patient has tried and failed conventional therapies, there is no question that tofacitinib would be a safe and effective alternative systemic therapy. Therefore, Xeljanz oral tablets 5 mg are likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Xeljanz oral tablets 5 mg are 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 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

The parent of a three-year-old male has requested coverage for continued 50-minute speech fluency treatment sessions for treatment of the enrollees dysfluent speech. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  He demonstrates significant speech dysfluencies as well as deficits in articulation skills.  Stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma.  Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously.  However, a certain number of children deteriorate, developing severe dysfluency.  For this latter group, if therapy is started early, the prognosis is favorable.  In this patients case, he has a family history of stuttering, significant speech dysfluencies, and articulation deficits.  His deficits in both speech fluency and articulation are negatively impacting his ability to communicate effectively.  Aggressive speech therapy offers him the best chance for full recovery.  All told, the requested continued 50-minute speech fluency treatment sessions are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested three-dimensional (3D) breast tomosynthesis for medical evaluation of her medical condition. Findings:  Three physician reviewers found that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the 3D breast tomosynthesis performed in this clinical setting. The medical literature reported the effect of integrated 2D and 3D mammography in population breast-cancer screening. The medical literature concluded that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. Randomized controlled trials are needed to compare integrated 2D and 3D mammography with 2D mammography for breast cancer screening. Although more studies may be needed, there is support in the medical literature supporting the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.Final Result: The reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Urgent Care
Decision: Overturned

A 26-year-old male enrollee has requested services on an emergent basis. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the enrollees circumstances would have sought immediate medical attention on the date of service at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.  In this patients case, he has been diagnosed with multiple sclerosis and has been treated on a routine schedule with medication.  These treatments have been prescribed on a once monthly basis.  Per the current medical evidence, it is important that the patient remain on the scheduled monthly dosage of the medication at issue in order to prevent an exacerbation.  A prudent layperson with multiple sclerosis would stay on schedule with this medication, even while traveling.  The patients symptoms on the date of service at issue met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his health in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of enrollment in a Phase I clinical trial for the treatment a malignant neoplasm of the tongue, head and neck.  The health plan denied the enrollees request indicating that the proposed trial is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that enrollment in the clinical trial is not likely to be more beneficial for treatment of the enrollees cancer than any available standard therapy.  Because two of the 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.