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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. The Child and Adolescent Level of Care Utilization System is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2.  The patient has no prior history of suicide attempts. At admission, the patient did not have any suicidal ideation or homicidal ideation. The patient does have a history of being violent when intoxicated. He did not have any psychosis, mania, or hallucinations. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment. The records document severe deficits in his interpersonal relationships and his ability to engage in socially constructive activities. He has been able to attend to his activities of daily living. In terms of comorbidity, the records support a score of 3. The patient has comorbidities of attention deficit/hyperactivity disorder, persistent depressive disorder with intermittent major depressive episodes, cannabis use disorder, and unspecified anxiety. He did not have medical problems which required 24-hour monitoring. With regards to environmental stress, the records support a score of 2. The patient has a mildly stressful environment. He has a supportive family. The patient has interpersonal conflicts with his parents over his substance use. In terms of environmental support, the records support a score of 2. The patient has supportive parents who are willing to participate in treatment. With regards to resiliency, the records support a score of 3. The patient has had an equivocal response to prior treatment and continues to struggle with substance use. In terms of acceptance and engagement, the records support a score of 3. The patient is passively cooperative with treatment. He has ambivalent relationships with his providers. Thus, the patient has a composite score of 18. Based on these criteria, the patient would meet criteria for an intensive outpatient program and could be treated in a less restrictive environment. Therefore, residential treatment center services were not and are not medically necessary for the treatment of this patient. 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 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: Upheld

A 41-year-old male has requested bariatric surgery for treatment of his obesity.  Findings:  The physician reviewer found that based on review of the available records, this patient meets the standard medical necessity criteria for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines. However, the surgeons assessment recommending pre-operative weight is based on clinical judgment. Further, pre-operative weight loss to 422 pounds is supported in the medical literature as resulting in significant improvement of visceral fat, thereby optimizing the patients intra-abdominal anatomy. Given the surgeons medical opinion that the patient should undergo weight loss as a pre-operative requirement to bariatric surgery, the requested procedure is not medically necessary until the weight loss has been achieved. Consistent with these findings, the requested bariatric surgery is not medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for varicose vein sclerotherapy. Findings:  Two of the three physician reviewers found the documentation does not support the superior efficacy of the requested services.  This patient has undergone a fairly extensive interventional procedure that included embolization of numerous pelvic veins. However, the records do not document a follow-up evaluation. No follow-up study was provided with respect to the venous system, and there was no assessment of arterial perfusion in a patient with leg symptoms despite venous interventions. There is no documentation of ongoing activity limiting symptoms. All told, the requested varicose vein sclerotherapy is not likely to be more efficacious than other available treatment options. Final Result: The 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 reviewers 1, 2 and 3 are board certified in vascular 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 43-year-old female enrollee has requested individual mental health psychotherapy 5 times per week for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the provider justifies the current treatment plan based on the fact that the patient has improved over the nine years that she has been engaged in therapy. The provider indicates further that the patient does not do well without the therapy and it should therefore be continued. Nevertheless, the records actually suggest the patients treatment is failing to address how the patient is being prepared to trust others or to deal with loss. Thus, it appears the patients therapy is not based upon the maintenance of a health benefit as the treatment plan is not progressive and does not utilize collegial consultation. Moreover, the records do not indicate that alternative modalities simultaneous to the patients treatment, such as group therapy, which have been very effective for those with trauma related diagnoses, have been attempted. For these reasons, the treatment modality has not been demonstrated to have been medically necessary for any number of psychotherapy visits per week. Thus, the medical necessity of the psychotherapy visits, or that these sessions be conducted by this specific therapist, has not been demonstrated in the records provided for review.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the psychiatric services provided were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency consists of a patient who is an imminent danger to himself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation with active plan, homicidal ideation, delusions, and delirium. In this case, the patient had ongoing chronic suicidal ideation. However, the patient did not have intent to act on suicidal ideation. In addition, the records do not show that the patient was in imminent danger to self. Moreover, IOP programs are not considered emergency psychiatric services. For the reasons provided, 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 66-year-old female who was diagnosed with fibromyalgia, cervical spondylosis, and chronic pain syndrome is requesting authorization and coverage for morphine. Findings:  The physician reviewer found that e patients sensation, strength, and reflexes were reported to be intact. The patients provider noted that the patient was involved in a car accident due to falling asleep while driving. The provider noted safety concerns for the patient and recommended tapering off morphine. A pain management specialist did not recommend opioids for the patients chronic pain and agreed with the plan to taper off opioid medications. Non-opioid therapy was recommended to treat the patients fibromyalgia. At issue in this case is whether morphine is medically necessary for treatment of this patients medical condition. The use of strong opioids in patients with fibromyalgia is not recommended due to a lack of efficacy, and the high risk of side effects and/or addiction. Strong opioid use is discouraged, and patients who continue to use opioids should show improved pain and function. Further, the Federation of State Medical Boards states that continuation, modification, or termination of opioid therapy for pain is contingent on the patients progress toward treatment objectives, and the absence of risks or adverse events. Behaviors that require modification or termination of opioid therapy include patient intoxication and impairment. In this case, the patient was diagnosed with fibromyalgia and chronic pain syndrome. The records indicate that she was treated with morphine and was involved in a motor vehicle accident due to falling asleep while driving. The provider noted safety concerns and recommended tapering the patient off morphine. Since the records do not report that the patient has progressed toward treatment objectives and there is a risk of adverse events, morphine is not supported as medically necessary for 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 reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sublingual immunotherapy (SLIT) and oral immunotherapy (OIT) for treatment of the enrollees medical condition. Findings:  The physician reviewers found that OIT is a treatment in which food-allergic patients consume gradually increasing quantities of the food to increase their threshold for an allergic reaction. This therapy carries a significant risk of allergic reactions. The ability of OIT to desensitize patients to particular foods is well-documented, although the ability to induce tolerance has not been established. SLIT involves the administration of small drops of allergen extract under the tongue, which is then eventually spit out or swallowed. SLIT therapy for allergic rhinitis carries a significantly less risk for severe systemic side effects given the sublingual route of administration, as opposed to subcutaneous immunotherapy. Recent studies show promising data for the use of immunotherapy in food allergic patients. However, therapies such as OIT and SLIT are not recommended for routine clinical practice. The current standard of care in the treatment of food allergies is allergen avoidance and ready access to self-injectable epinephrine. Final Result: Two of three 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 reviewers number one, two, and three are board certified in allergy and immunology and 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 59-year-old female enrollee has requested for anterior L4-5 and L5-S1 discectomies and intervertebral fusions with femoral ring allograft bone grafts, autogenous local bone graft and calcium phosphates and placement L4 to S1 bioabsorbable buttress screws, followed by a posterior revision L4-5 left microdiscectomy/decompression, posterior revision L4-5 right decompression, posterior revision L5-S1 right decompression, L4 to S1 posterolateral instrumented fusions with pedicle screws, autogenous local bone graft, allograft bone graft and calcium phosphates for treatment of her low back pain.  Findings:  The physician reviewer found that surgery for radiculopathy with disc herniation or symptomatic spinal stenosis may be of benefit, but for non-radicular back pain associated with degenerative changes, it is no more effective than rehabilitation. Fusion may be indicated in specific pathologies and instabilities, but low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion. Although MRI is an excellent tool to study morphology, these findings must be related to clinical examination and other studies to provide meaningful judgments.  In this patients case, the indications for spinal fusion have not been documented. There is no documentation of instability on the radiologic studies.  EMG/NCV evaluations on two occasions indicated the presence of polyneuropathy rather than radiculopathy. The polyneuropathy was not evaluated based upon the submitted documentation.  No consistent pattern of neurologic loss on examination is documented.  There is limited documentation of non-surgical management prior to the recommendation for fusion.  All told, the requested procedures are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 12-year-old male enrollee has requested emergency services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent medical condition means 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: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. Several of the major reasons complained of by the enrollee's parent including abdominal pain, inability to walk or eat, are not supported in the documentation provided based on physical examination by the treating nurses, physician assistant, and supervising physician. The acute onset of severe abdominal pain, inability to ambulate, or dysphagia are all symptoms that would lead a reasonably prudent layperson to seek care at the ED. However none of these symptoms are documented in this patients history of present illness, review of systems, physical exam, diagnostic tests, assessment, plan, or instruction section of the ED visit note. The records document a patient with nasal congestion without difficulty breathing, vomiting, diarrhea, or abdominal pain. The patient presented with normal vital signs and was described as alert, attentive, smiling, active, and playful on examination. In the absence of medical documentation to support severe abdominal pain, inability to ambulate, or inability to eat as the reason for emergent medical care, this patients situation does not meet the definition of an emergency medical condition as set forth by California law.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested lumbar surgery for treatment of his low back and leg pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested surgery. In this case, there is no documented lumbar instability, fracture, or tumor. Also, there is no documentation of a recent trial and failure of adequate conservative measures to include six weeks of physical therapy for back pain. In addition, there is no documentation of failure of previous fusion surgery. For the reasons provided, the requested surgery is not clinically indicated and not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. As such, Orthovisc injections in the left knee are medically necessary for management of this patients osteoarthritis.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 representative of a 19-year-old male enrollee has requested seven additional intensive outpatient therapy sessions for treatment of the enrolle's behavioral health condition. Findings:  The physician reviewer found that the course of substance misuse illness is consistent with that of other chronic illnesses: it is characterized by episodes of illness, partial recovery, remission and recurrence. Thus, recurrence of illness, or partial recovery, as in the patients continued intermittent use of cannabis is consistent with the known course of his illness. In the presence of illness, it is therefore appropriate that he continues to receive more treatment, not less. Prochaska and DiClemente's Transtheoretical Model (Six stages of Change) explains how patients cycle through the process of motivation and change several times before being able to sustain stable change. Motivational Interviewing  (Miller and Rollnick) as is being incorporated into his IOP, will help facilitate his move towards stable change. A 12-step program may be a useful adjunct, but it is not an adequate substitute for IOP for this patient. In addition, he remains with significant psychotic symptoms, confusion, and now the emergence of anxiety symptoms (as is common in patients as their psychosis subsides and insight improves, the patient is faced with the reality of their illness). In summary, this patient remains with significant illness and continued psychotherapy, evaluation and medication management at his IOP program should be resumed and is medically necessary for the seven additional sessions requested.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested for an eating disorder intensive outpatient program for treatment of her eating disorder.  Findings:  The physician reviewer found that applying the American Psychiatric Association (APA) practice guidelines for the treatment of patients with eating disorders, this patient is a candidate for treatment in a less restrictive setting. Wilson and colleagues also endorse the efficacy of outpatient treatment modalities. Without evidence of significant co-morbid conditions, the patient may well benefit through outpatient therapy, but her condition does not require the intensive services offered through an IOP.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar fusion for treatment of the enrollees lumbar stenosis. Findings:  The physician reviewer found that this patient presents with chronic back pain. He has had lower extremity pain, numbness and subjective weakness. On recent examination by his provider, there was no atrophy or weakness on individual muscle testing. He has had a history of a slapping left foot. The patients symptoms have not reportedly been evaluated with electromyography/nerve conduction velocity (EMG/NCV) testing nor has he had a Tinels sign on examination at the fibular head to rule out a peripheral cause of his symptoms. There is no documentation of failed conservative management with physical therapy addressing his back condition, injections, epidural steroid injections, or chiropractic treatment. He has not had a hip, knee, foot, ankle examination, sacroiliac joint examination, nor a vascular examination to rule out other possible causes of pain, numbness, and weakness. He has had ill-defined lower extremity symptoms without dermatomal/myotomal symptoms or findings consistent with a lumbar radiculopathy. He has an abnormal MRI scan at L4-5, but there is no correlation of his imaging with his clinical examination. Thus, the criteria for lumbar spinal fusion has not been met. There is no evidence of lumbar radiculopathy, spondylolisthesis with neurogenic claudication, and failure of conservative management in past six weeks to three months. Further, there is no motor weakness consistent with imaging findings, rapidly progressive neurologic findings that correlate with imaging, and other treasonable causes of pain have not been ruled out. Thus he fails to fulfill criteria for decompression/discectomy/fusion. As noted by a study, in the absence of deformity or instability, the inclusion of a fusion is not recommended.  Final Result: The reviewer determined that the requested surgery 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 neurological 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.