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

A 50-year-old male enrollee has requested autologous cell therapy injection for the treatment of his osteoarthritis of the left knee.  Findings:  The physician reviewer found that there is a paucity of medical literature supporting the clinical value of autologous cell injection therapy for the treatment of osteoarthritis. While there is some evidence available regarding the use of the requested therapy for tendon repair, it has not been established as an accepted modality for osteoarthritis. There are multiple standard alternative treatments available for management of this patients medical condition that are likely to produce more beneficial results than the requested therapy. As noted by Storrs, currently there are clinical trials underway that should provide more data within the next year on the safety and long-term efficacy of autologous cell injection therapy with platelet-rich plasma.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tadalafil 10 mg tablets. The submitted documentation fails to demonstrate the medical necessity of the requested medication. A study found while tadalafil is a potential treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia, it is not considered a first-line therapy. Following failure of alpha adrenergic blockade for documented symptomatology or measured abnormalities of voiding function, a trial of 5-alpha-reductase inhibitors may be appropriate. In this patients case, the records do not definitely document lower urinary tract symptoms related to benign prostatic hyperplasia. Thus, tadalafil 10 mg tablets are not medically necessary 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 reviewer is board certified in urology 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 injection therapy, immune globulin (Gammagard liquid), nonlyophilized, 500 mg. Moriguchi and colleagues noted that a study of four patients with neuralgic amyotrophy treated intravenous immunoglobulin infusion (IVIg) therapy showed good response. Naito and colleagues reported that nine out of then patients with neuralgic amyotrophy who received IVIg therapy with methylprednisolone pulse therapy (MPPT)  showed clinical improvement of motor impairment. In this case, the patient has tried and failed steroid therapy. Given the providers recommendation and current medical literature, the requested service is medically indicated. Therefore, injection therapy, immune globulin (Gammagard liquid), nonlyophilized, 500 mg is medically necessary for the treatment of this patient.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 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services on an emergent basis or urgent basis. Findings: The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. 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. OCD is a chronic psychiatric condition with varying degrees of impairment characterized by intrusive thoughts, or obsessions, and, time-consuming and ego-dystonic repetitive behaviors, or compulsions. Like most long-lasting mental illnesses, there may be times when OCD is more problematic than others. In this case, the IOP level of care was indicated as the patient was prominently symptomatic despite appropriate treatment in the outpatient setting. The patient was enduring an acute-on-chronic exacerbation of illness. Considering the infringement on activities of daily living and suicidal ideation in context of previously established OCD and the recommendation for IOP services from the treating provider, immediate medical attention was needed. The presence of an acute deviation from baseline with suicidal ideation is consistent with a psychiatric emergency medical condition. The patient had a severe mental illness and needed immediate IOP treatment. The services at issue were necessary for treatment of a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient received psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be 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.
Appeal type: Experimental/Investigational
Decision: Overturned

ANature of Statutory Criteria/Case Summary: An enrollee has requested corneal collagen cross-linking with riboflavin for treatment of the enrollees keratoconus. Two physician reviewers found that recently, the U.S. Food and Drug Administration (FDA) indicated that it would recommend approval for the riboflavin compound that is used in corneal cross-linking therapy. The available peer-reviewed medical literature includes studies that demonstrate cross-linking therapy in cases of keratoconus can result in earlier corneal stabilization without having to resort to invasive procedures like penetrating keratoplasty. All told, the corneal collagen cross-linking with riboflavin was likely to have been more beneficial to this patient than the available standard therapy. Final Result:  Two reviewers determined that the services at issue were 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: All three reviewers are board certified in ophthalmology and are actively practicing. All three 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: An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) level of care mental health services. At the time of admission, the patient did not meet the American Psychiatric Association (APA) requirements for treatment at the PHP level of care. She was not suicidal, homicidal or psychotic, and her level of functioning was not deteriorating. The patients mood has improved and she has responded well to medications. The patients current symptoms can be safely and adequately addresses in the outpatient venue. DBT is the first-line treatment for self-harm and borderline personality traits. In addition, intensive family therapy is indicated for the treatment of the patients reactive attachment disorder. All told, the PHP level of care mental health services 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 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 51-year-old female enrollee has requested Vicodin 5/500, one tablet every four hours, and Soma, four times per day for treatment of her back pain.  Findings:  The physician reviewer found that this patient has taken short-term narcotics with the recent addition of MS Contin by her new primary care physician.  Additionally, she has used Soma up to four to five times per day. The patient refused to see a pain specialist and has seen multiple primary care physicians in the past two years.  In this patients case, Soma is not medically indicated.  Soma is recommended for short-term (less than three months) use. Long-term use of this medication may have negative effects. New FDA recommendations and pain guidelines call for medications such as membrane stabilizers for use in chronic myofascial and fibromyalgia syndromes.  In this patients case, Soma is not medically necessary for this patient with multiple comorbidities, as this medication is not indicated for daily use for the treatment of a chronic condition.  On the said date, the patients provider prescribed Vicodin, one tablet, twice daily. Vicodin should be used sparingly in low doses due to addiction risk with short acting narcotics.  In this patients case, the prescribed amount of Vicodin, one tablet, twice daily, is medically indicated for the management of her pain.  Given the comorbidities of this patient, especially hypothyroidism, opiates are risky, as they can further suppress hormonal function and immune function.  All told, the requested Soma, four times per day, is not medically indicated for this patient.  Additionally, the patient has requested Vicodin 5/500, one tablet every four hours.  Although this amount is not medically indicated for this patients pain, Vicodin 5/500, one tablet, twice daily, is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested Supartz injections for treatment of her right knee osteoarthritis. Findings:  The physician reviewer found that there is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Rutjes and colleagues assessed the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis. This study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes et al). Moreover, the American Academy of Orthopaedic Surgeons guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Furthermore, several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint and in some cases requiring arthrocentesis after multiple injections. Based on the medical literature cited above, the requested therapy is 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 a 3-piece penile prosthesis procedure. Researchers conclude that penile prosthesis remains an important, viable, and effective treatment for male erectile dysfunction that does not respond to other less invasive approaches or when these approaches are contraindicated or not acceptable to the patient. In this case, while the records do not reflect physical findings and ejaculatory dysfunction, the documents reflect that the patients condition has been prolonged. He has tried and failed multiple treatment modalities, including psychotropic agents. In this clinical setting, the requested service is medically indicated. Therefore, a 3-piece penile prosthesis procedure is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 urology 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 45-year-old male with a history of anemia, hepatic encephalopathy and cirrhosis. He was admitted to acute care in October 2005 with acute alcohol intoxication. He was admitted to a skilled care facility (SNF) in October 2005. A physical therapy evaluation performed in October 2005 found the patient was alert and able to ambulate independently. The patients provider switched the patient from intravenous antibiotics to oral antibiotics and recommended discontinuation of skilled therapy. The Health Plan denied coverage for continued SNF services as of October 2005. At issue is whether continued SNF services are medically necessary for treatment of the patients medical condition.Based upon the evidence provided, the patient does not meet medical necessity criteria for continued SNF services. The submitted records indicate the patient was alert and oriented in October 2005 and was independent with mobility and ambulation. The patient does not require physical or occupational therapy and has no need for daily skilled nursing services. Though it appears the patient would benefit from treatment of his alcohol dependence, there is no indication for continued SNF services. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested rehabilitation at a skilled nursing facility for the treatment of his medical condition. Findings:  The physician reviewer found that the medical literature indicates that recovery after stroke occurs fastest in the first three months. Later recovery (up to one to two years after stroke) is also possible, especially between three to six months. Therefore, continued rehabilitation is generally appropriate for a patient who has had a recent stroke (within the last three months). While this patients condition was somewhat limited by his medical problems, he demonstrated some improvement during his stay in the skilled nursing facility and was continuing to progress.  In light of his capacity for further improvement, his continued stay during the time period in question was medically appropriate and indicated. Further, it is reasonable to provide the patient with additional skilled nursing facility services at this time. While the patients progress has been slow, there continues to be potential for improvement. Moreover, a skilled nursing setting will allow the patients medical problems to be addressed thus maximizing the amount of therapy that he can tolerate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 100 mg. Findings:  The physician reviewer found that Lyrica 100 mg is medically necessary for treatment for the patients chronic neuropathic pain. Gabapentin and pregabalin have similar safety and efficacy in the medical literature for chronic neuropathic pain. According to studies, pregabalin has a multidimensional effect across a range of disorders that have of a pathogenesis involving a central nervous system response of abnormal hyperexcitability. The use of pregabalin in these complex and difficult-to-treat conditions is associated with rapid and durable clinically significant improvements in several outcome measures relating to core symptoms, including pain, anxiety and sleep, and improvements in overall health status and health-related quality-of-life. In this case, the medical records document that the patient has physical exam findings and imaging studies consistent with neuropathic pain due to complex regional pain syndrome. Additionally, there is documentation showing that the patient failed other anticonvulsant medications in the same class due to severe adverse reaction to gabapentin. Given that the patient is exhibiting neuropathic or radicular pain and failed trials of similar medications such as gabapentin, Lyrica 100 mg has been established as medically necessary for this patient. 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for residential treatment center (RTC) services. Findings: The physician reviewer found that the diagnoses of alcohol abuse and anxiety.  She was hospitalized with a blood alcohol level of 0.48 after which she attended outpatient treatment.  She was hospitalized again with a blood alcohol level of 0.58 and then received treatment at an inpatient facility.  She was sober for a month, but then she spent additional days in a hospital after which she began outpatient therapy, but continued to drink. The enrollee indicates that despite outpatient and inpatient treatment, she continued to abuse alcohol and it was affecting her physical health, her family, and social life.  She also lost her job. She feels the residential treatment gave her the needed structure and support to begin recovery. All of the residential treatment center (RTC) services provided were medically necessary to treat the enrollee's medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a pain management provider. The medical documentation does not support the medical necessity of the requested services. Per the American Academy of Pain Medicines guidance, referral to a pain management specialist is appropriate when current treatment is not helping. In this case, the patient recently underwent two drug screens, both of which suggest that the patient is not taking Norco as prescribed (if at all). The patient has also very recently been prescribed gabapentin and has not yet completed the prescribed course of physical therapy. Since no evidence has been presented showing that the current treatments cannot help manage/cure the patients pain, referral to a pain management specialist is not appropriate at this time.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 54-year-old female enrollee has requested removal of excess belly fat for treatment of her excess belly fat.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate the medical necessity of the requested procedure. The typical complaints associated with an overhanging pannus include rashes, ulcerations, infection and pain of the abdomen that persist despite conservative measures.  There is no documentation of these complaints.  All told, the requested removal of excess belly fat is not medically indicated and is not reconstructive in nature.