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

The patient is a 48-year-old male who is status post left total hip replacement in February 2005.  Following surgery a 1.5cm leg length discrepancy was identified, with the left leg being longer than the right.  He has experienced persistent leg and back pain over the past year and has been treated with extensive physical therapy (PT).  The patient is requesting continued PT with Pilates/core strengthening.  The Health Plan has denied his request based upon their determination that the requested therapy is not medically necessary.It has been determined via radiographs that the patient has a 1.5cm leg length discrepancy.  This deficit is fixed, and will not change with PT or Pilates.  He has previously had 73 session of PT and was discharged with a recommendation for continued strengthening through a home exercise program.  The therapists notes indicated he was instructed in the home program and the patient should be able to continue further strengthening independently. While Pilates is another form of strengthening, there is no evidence that it is of superior efficacy to the type of treatment the patient has already received.  A review of the PT progress notes did not demonstrate that the prior therapy was deficient.  It was extensive and covered multiple strengthening and stretching exercises.  The patient has reached a plateau with skilled PT and Pilates techniques would not change this.  He should continue with his home program and utilize a heel lift.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee requested inpatient medical treatment for his obsessive-compulsive disorder. Findings: The physician reviewer found that an inpatient residential treatment program is medically necessary in this case.  This patient has trialed many medications at appropriate doses with only marginal improvement.  He has received intensive case management services, and he has been active in various psychotherapies across the spectrum of treatment settings.  The patient has had multiple acute hospitalizations due to anxiety, depression and suicidal ideation.  He has a complicated disorder that has not adequately responded to less intensive interventions.  This patients obsessive-compulsive disorder has been refractory to comprehensive treatment efforts and requires specialized treatment services.  Therefore, inpatient programming focusing on obsessive-compulsive disorder is reasonably expected to improve the patients condition.  All told, non-acute inpatient residential programming is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female with chronic pain secondary to reflex sympathetic dystrophy of her left shoulder. She is requesting coverage for Actiq. Treatment has included lidoderm patches, Actiq lozenges, nortriptyline, Gabitril, nerve blocks, physical therapy and cognitive behavioral therapy. The patients provider indicates the patient can no longer use Darvocet, Bextra, Vicodin and Percocet due to severe nausea and abdominal pain. The patient has requested authorization and coverage for continued use of Actiq. The Health Plan has determined the requested medication is not medically necessary for treatment of the patients condition.Actiq is a short-acting narcotic with clearly limited indications. Actiq is approved for cancer related chronic pain syndromes refractory to the usual narcotic and other pain management techniques. It is not intended for use in other pain syndromes. There is no evidence Actiq is medically indicated for this patient. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa. Based on the records provided for review, the patient presents with hypertriglyceridemia that does not exceed 500 mg/dL and is not associated with any documented coronary disease or pancreatitis. The records suggest that treatment of this patients hypertriglyceridemia is being considered to help reduce his overall cardiovascular risk. However, randomized trials have not directly compared most agents for the reduction of cardiovascular risk in patients with hypertriglyceridemia. Although statin therapy is generally less effective in reducing triglyceride levels compared to other therapies, the proven efficacy of statins to reduce cardiovascular risk supports their utility when cardiovascular risk reduction is the primary goal of treatment. Moreover, there is a lack of data demonstrating that targeting treatment to lower triglyceride levels reduces overall cardiovascular risk in patients with significantly elevated LDL cholesterol. This patients records document only one statin trial and no other attempts at statin therapy. Since the patients hypertriglyceridemia is not severe as defined by over 500 mg/dL, and there is no documented treatment failure or intolerance to other statin medications, Vascepa 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 internal medicine with subspecialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a computed tomography (CT) angiography scan. Findings:  The physician reviewer found that the records did not reflect that the patient had clinical symptoms of coronary artery disease and noted that the patient was on lipid lowering therapy. In this clinical setting, the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend preventive interventions, including blood pressure and lipid management. Given that a coronary CT angiography would not provide additional clinical data to alter the appropriate management or to improve the outcomes in an asymptomatic patient, the service at issue was not medically indicated. Therefore, a CT angiography scan  was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for an evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld

The patient is a 71-year-old male who apparently has lower urinary tract obstructive symptoms caused by benign hypertrophy (prostatism). A cystoscopy report has not been submitted and therefore, the patients apparent diagnosis has not been fully confirmed. The patients provider has recommended treatment with Flomax. The Health Plan has denied this request and recommended treatment with Hytrin or Cardura.There are two types of non-surgical treatment with medications known to be effective in the treatment of prostatism  alpha blocking medications, which relax the nerves that tighten the bladder neck and 5-alpha reductase inhibitors, which block the transformation of testosterone to dihydrotestosterone. Each class of drug has a different mechanism of action and each has its own pattern of side effects. The alpha blocking medications usually work faster than the 5-alpha reductase inhibitors. Although Flomax is a newer drug than Hytrin or Cardura, all of the drugs are effective for the treatment of prostatism. Furthermore, there is no evidence demonstrating that Hytrin or Cardura are contraindicated for treatment of the patients condition. Therefore, based upon the information provided, I have determined the Health Plans denial should be upheld. However, should the patient have any contraindication to Hytrin or Cardura or should the patient develop intolerance to these medications or should these medications prove ineffective, the Health Plan should authorize Flomax.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a female with a history of mandibular anterior pain. She did undergo treatment of teeth in the area. However, as the lesion persisted, she was referred to an oral surgeon for evaluation who found her to have a large radiolucent lesion which crossed the midline and extended in the area from teeth numbers 21 and 28. Given this finding, a biopsy of the area was recommended and this was performed. The lesion was found to be consistent with a central giant cell granuloma. She was referred to otolaryngology for further treatment. The patient has requested reimbursement for emergency services provided. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. At issue in this case is whether the enrollee received emergency medical services on the date(s) of service in question. 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. The patient did have a lesion within her mandible and was symptomatic. Given the presence of the lesion, immediate biopsy of the lesion was indicated. The importance of early biopsy is imperative as aggressive pathology needs to be ruled out. The biopsy would then guide management of this lesion after histological evaluation. Given that the patient was symptomatic, performance of the procedure on an immediate basis was warranted. The emergency services provided were necessary for treatment of an emergency medical condition. Thus, the patient did receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did receive emergency medical services for treatment of an emergency medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Upheld

The enrollees parent is requesting authorization and coverage for 60 days of RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollees composite CALOCUS score correlates with Level IV, Medically Monitored Community Based Services.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old female status post vertical banded gastroplasty. Her body mass index (BMI) is 30 with reported reflux esophagitis and solid intolerance. The patient has requested authorization for gastroplasty revision and conversion to Roux-en-Y gastric bypass. The Health Plan has denied the patients request indicating that Roux-en-Y gastric bypass is not standard of care for surgical treatment of GERD, gastritis, and esophagitis.  The patients current BMI in the absence of any comorbid criteria precludes any indication for gastric bypass surgery. The patient indicates that she wishes to undergo conversion to a Roux-en-Y gastric bypass so that she can consume normal, healthier meals; however there is a high incidence of solid intolerance after Roux-en-Y gastric bypass. Furthermore, there is a risk of protein malnutrition after Roux-en-Y gastric bypass since most patients are not able to tolerate eating meat. Thus, conversion to Roux-en-Y gastric bypass for treatment of the patients reflux esophagitis is not medically indicated in the absence of morbid obesity. If the patients GERD, gastritis, and esophagitis symptoms are severe enough, removal of the gastroplasty ring may be indicated to solve her reflux problems.Based upon the information set forth above, 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 has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that in managing patients with chronic hepatitis C virus, denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. Moreover, a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. For the reasons provided above, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients hepatitis C virus genotype 1.   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 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 55-year-old male enrollee has requested for the prescription drug Lovaza for treatment of his mixed hyperlipidemia. Findings:  The physician reviewer found that Lovaza is generally used for treatment of primary hypertriglyceridemia, which is not the primary abnormal lipid in this patient. If treatment of hypertriglyceridemia is desirable, in addition to treatment of LDL cholesterol, the other medications recommended are more clinically appropriate in this type of therapy than Lovaza. The information presented does not demonstrate that Lovaza is indicated or clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-400 mg. 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. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Upheld

A 41-year-old female enrollee has requested for use of a continuous passive motion (CPM) device for treatment of her left knee status post total knee arthroplasty.  Findings:  The physician reviewer found that a review of peer-reviewed Level 1 and Level 2 studies in current medical literature does not support the use of continuous passive motion (CPM) device in the home following total knee arthroplasty. There is no significant increase in range of motion in the long-term from the use of a CPM machine following total knee replacement surgery. The references cited above are consistent with this determination. Objective evidence that CPM results in improved clinical outcomes is lacking at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested mental health residential treatment center services for treatment of the enrollees behavioral health condition.  The physician reviewer found that the mental health residential treatment center services were and are medically necessary for treatment of the patients medical condition. Based on the documentation provided, specialty services at the residential level of care were and are indicated for this patient struggling with the developmental stage of identity formation who has yet to consolidate the treatment gains necessary to succeed in a less restrictive setting. Further, considering her previous suicidality and acute psychiatric hospitalizations coupled with her suboptimal family situation, a conservative treatment course is to be expected.  The developmental perspective is a key component of consideration. This patient demonstrates unrefined intrapsychic defenses, self-defeating coping strategies and a fragmented sense of self which manifests with defiance, impulsivity and ambivalence.  This patient evidences struggles in achieving a healthy second individuation, with role diffusion championing, and a complete lack of formal operational thought.   The psychiatrist noted the patients anger, anxiety and limited interpersonal skills, and increased one of her medications. This patient lacks the psychological maturity to succeed in a less restrictive environment. In sum, the services in dispute were and are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Furthermore, a three-month residential admission followed by step-down to a partial hospital program would be consistent with community practice standards in a case such as this. Final Result: The reviewer determined that the services at issue were and 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 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: Urgent Care
Decision: Upheld

A 68-year-old female enrollee has requested emergency services for the treatment of her groin pain. Findings:  The physician reviewer found that the patients symptoms did not meet the prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and intermittent, moderate groin pain for two weeks would not reasonably expect the absence of emergency care to jeopardize their health. The medical documentation does not support the patients assertion that she could not bear weight on her leg without screaming.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cardiac computerized tomography (CT) scan for calcium scoring. Findings: Based on current medical literature, coronary artery calcium (CAC) scoring has been shown to be of benefit in those with intermediate risk, defined as a ten-year risk of coronary artery disease of at least 7.5% and in some cases as low as 5%. In this case, the American College of Cardiology calculated ten-year coronary artery disease risk score is less than 2% for this patient. Given that the patient has a very low ten-year risk for coronary artery disease, and as bicuspid aortic valve is not an established risk factor for coronary artery disease but rather a risk factor for aortopathy and aortic stenosis, the requested service is not medically indicated. Therefore, cardiac CT scan for calcium scoring is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular 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.