Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

A 21-year-old female enrollee has requested emergency services for her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. 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. The submitted medical records indicate the patients symptoms had commenced one week prior to her exam. Her symptoms consisted of vaginal itching. She did not report any abdominal pain, vomiting, fever, or any other ominous symptoms. The patients physical exam was unremarkable, and she did not require any medications in the emergency department. The records provided do not document the presence of severe vaginal discharge or pain that would likely preclude one from driving. Further, although the patient reports no history of yeast infections, prior to presenting to the emergency department she had tried an over-the-counter medication for yeast infection which had provided some relief. All told, a prudent layperson in this patients circumstances would not reasonably expect the absence of immediate medical attention to result in serious jeopardy to her health, impairment to bodily function or serious dysfunction of a bodily organ or part. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an urgent or emergent basis. This patients symptoms do not meet the criteria for an emergency medical condition under California law.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for community-based adult services. The records document that this patient has multiple health conditions that require dietary management, lifestyle interventions such as exercise, and compliance with medical treatment, including pharmacotherapy. The provider noted that the patient has adequate cognitive faculties, physical capacity, and resources with respect to her durable medical equipment with use of a home blood pressure cuff and home glucose monitor to manage her medical conditions. The patient is able to manage her basic self-care, instrumental activities of daily living, and mobility in the home and community settings. There is a lack of indication in the records that the patient requires community-based adult services. Although the patients compliance with treatment has been suboptimal, no substantive and marginal difference in her clinical course or outcomes is reasonably expected with the addition of the proposed services over compliantly followed management for her underlying medical conditions. For these reasons, the requested community-based adult services are not medically necessary for treatment of this patient. 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 physical medicine and rehabilitation 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 23-year-old female enrollee has requested for residential treatment for treatment of her eating disorder. Findings:  The physician reviewer found that the patient did indeed respond positively to residential care and achieved her goal weight.While her medications continued to require adjustment, this did not require 24-hour supervised care. The patient did not have more than a single behavior that impaired recovery by this time and her progress was such that she could have safely and effectively transitioned to a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested a laparoscopic sleeve gastrectomy for treatment of his morbid obesity. Findings:  Three physician reviewers found that the laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of diabetes, hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Furthermore, this patient has several unique clinical issues that make the choice of the laparoscopic sleeve gastrectomy a better option as compared to laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic gastric banding (Lap-Band). The patient is status post cardiac transplant and is on immunosuppressive medications and therefore the Lap-Band is a relative contraindication given the risk associated with a foreign body. The patient is also taking non-steroidal anti-inflammatory drugs (NSAIDs) and steroids which are a relative contraindication for LRYGBP as both will promote ulcer formation. The laparoscopic sleeve gastrectomy does not involve the use of a foreign body or malabsorption of vitamins or medications, making it the best clinical option for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 23-year-old female enrollee requested antigen leukocyte cellular antibody testing (ALCAT) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that high-quality controlled trials of ALCAT are not available.  The test has been characterized in the literature as lacking scientific and clinical proof of efficacy.  The National Institute of Allergy and Infectious Diseases (NIAID) guidelines for diagnosis of food allergy do not recommend ALCAT testing.  Given the lack of controlled trials and the lack of support from medical society clinical guidelines, the superior effectiveness of ALCAT testing in this clinical setting has not been established.  Therefore, ALCAT testing was not likely to have been of greater benefit than other available methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Dexcom G5 Mobile Continuous Glucose Monitor for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that a continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. Continuous glucose monitors can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. Continuous glucose monitoring can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. It can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. Continuous glucose monitors have been shown to improve hemoglobin A1c levels of diabetic patients.  The current medical evidence supports the requested equipment in this clinical setting. Therefore, the Dexcom G5 Mobile Continuous Glucose Monitor is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. The medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence does not support viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where options are limited. In this case, the patient reported an excellent response to prior viscosupplementation, with pain relief and improved function. Furthermore, his options are limited, with the alternative being a total knee arthroplasty. Therefore, Orthovisc injections are 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 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: Upheld

The patient is a three-year-old female with diagnoses of cerebral palsy with spastic quadriplegia and microcephaly.  She was born at full term and delivery was complicated by meconium aspiration requiring two days of ventilatory support.  The patient has been receiving traditional physical therapy (PT) since her diagnosis of cerebral palsy approximately three years ago.  The record did not include progress notes from the earlier PT.  The patient has been receiving intensive physical therapy based upon a model that includes the TheraSuit and Spider therapy since June 2005.  The Health Plan has denied coverage and prospective authorization for the intensive physical therapy program based upon their determination that it is not medically necessary or medically appropriate.In reviewing the literature, there was no documented evidence that intensive therapy of this type is better than standard therapy. The only literature available was one small study from Japan using a different type of intensive therapy. The consensus in the scientific community is that little functional benefit is realized from these programs.Based upon the information set forth above, I have determined the therapy at issue was/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 33-year-old female enrollee has requested partial hospitalization program services for the treatment of her condition. Findings:  The physician reviewer found that the patient's need for this care was apparent. She was clearly unable to make progress at a lesser level of care; her psychopathology is documented in the statement submitted by her providers and her treatment plan clearly met her needs. Her time in RTC was lengthy, but she was deeply impaired. I believe her RTC treatment was medically indicated and appropriate. The patients subsequent treatment in two PHPs, as well as her current and future treatment in IOP is most appropriate, clinically indicated, and medically necessary. She is being stepped down in a manner consistent with her complex psychiatric and medical conditions. She remains fragile and to step her down any more aggressively is to risk regression and dissipation of the gains she so painfully achieved. Her treatment has been difficult but well managed by her providers. I recommend that all denials of the patients PHP treatment be reversed. Further, I believe her IOP treatment is medically appropriate and indicated. Any denials for these services should also be reversed. I also endorse the plan to transition the patient to outpatient psychotherapy in the reasonable future.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-month-old male enrollee has requested for physical therapy and occupational therapy services for treatment of the enrollees hypotonia and developmental delay. Findings:  The physician reviewer found that global developmental delay is defined as a significant delay in two or more of the following developmental domains: gross/fine motor, speech and language, cognitive, social/personal, and activities of daily living. It involves a profile that is associated with age-specific deficits in adaptive and learning skills. Those deficits are evident in comparison with the skills obtained by chronological peers. (Shevell, et al.) The main goal of treatment is to enhance the level of functioning. This patient has noted delays of greater than 50% in his gross motor skills, fine motor skills, and adaptive skills. The patient has an underlying chromosomal abnormality with clinical impression of Beckwith Wiedemann Syndrome. Developmental delay is associated with paternally derived duplications of 11p15 detectable by cytogenetic analysis (Shuman, et al). Standard intervention such as infant stimulation programs, including occupational and physical therapies, are often utilized for children with significant functional deficits secondary to Beckwith Wiedemann Syndrome and developmental delay (Shuman, et al).
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested for a continuous glucose monitoring system (CGMS) for treatment of his diabetes. Findings:  The physician reviewer found that CGMS, used appropriately, on a periodic basis and under the auspices of an endocrinologist, is not experimental or investigative and may be medically necessary to periodically monitor a labile patient.Poor control with frequent hyperglycemia or recurrent episodes of severe hypoglycemia might require the use of a CGMS device to initiate changes in food intake or insulin in order to optimize blood sugar control.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee has requested a breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that the guidelines for the use of breast MRI are well documented in the peer-reviewed literature. For patients with breast pain, the standard of care is a diagnostic mammogram and/or breast ultrasound. The utilization of breast MRI in patients with breast pain and a normal mammogram, physical exam and breast ultrasound is not medically indicated. Screening breast MRI is used only for patients with a calculated risk of developing breast cancer of greater than 25%, patients with personal or family history of BRCA mutation or patients with history of radiation therapy to the chest region. Diagnostic breast MRI is used for patients where diagnosis is inconclusive, even after standard work-up; evaluation of the post-operative patient when scar tissue cannot be differentiated from tumors; patients with positive axillary nodes but no known primary; patients with rupture of a breast implant; and for determination of the extent of disease in patients with known malignancy, prior to treatment. This patient is not at high risk for developing breast cancer as there is no documented family history of breast cancer or BRCA mutation. Moreover, the patient does not have a history of radiation therapy to the chest wall, or inconclusive diagnosis on mammogram or breast ultrasound. Further, there is no evidence of an implant rupture. As this patient does not meet the established criteria for screening or diagnostic breast MRI, the requested breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Per the medical evidence, there is increasing evidence of value of tomosynthesis in breast imaging related to the tomographic technique and the associated ability of radiologists to differentiate glandular tissue from underlying architectural distortion or mass.  There is ample data showing decreased callbacks and increased detection of small cancers when tomosynthesis has been added to the usual two-dimensional mammographic images.  Thus, the addition of breast tomosynthesis to the two-dimensional mammogram films was likely of more benefit to the patient than if two-dimensional mammography alone had been done. Final Result: Two reviewers determined that the services at issue were 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:   All three reviewers are board certified in diagnostic radiology 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

A 38-year-old female enrollee has requested a custom knee brace #L1845 for the treatment of her status post left knee anterior cruciate ligament reconstruction. Findings:  The physician reviewer found that the requested anterior cruciate ligament reconstruction functional brace is not medically indicated. Although the physician states that the brace is necessary to protect the knee following surgery, the patient does not have exam evidence of ongoing instability.  The American Academy of Orthopedic Surgeons (AAOS) has issued a consensus statement upon reviewing medical literature regarding functional braces following anterior cruciate ligament reconstruction. Although many surgeons in the past utilized functional knee braces following anterior cruciate ligament reconstruction, AAOS has concluded that postoperative functional bracing is not necessary after a well-performed anterior cruciate ligament reconstruction without instability.  The consensus statement indicated that there was no true protection of the anterior cruciate ligament by the brace, and there was no change in the incidence of recurrent tears postoperatively. Most orthopedic knee specialists and sports medicine specialists have, therefore, abandoned the use of postoperative functional bracing following uncomplicated anterior cruciate ligament reconstruction surgery in the absence of objective instability postoperatively.
Appeal type: Medical Necessity
Decision: Upheld

A 74-year-old female enrollee has requested for skilled nursing facility care for treatment of her status post fracture dislocation of the right ankle. Findings:  The physician reviewer found that the medical records noted that the patient made significant progress with skilled nursing services.The patient required minimal assistance for sit to stand and stand to sit, and she had fair balance. There was no documentation indicating that the patient required continued skilled level of care nursing or therapy services. The submitted medical records do not demonstrate that the patient was expected to make measurable gains in a predictable period of time with continued skilled nursing level of care services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Community-Based Adult Services (CBAS) non-residential day program.Appropriate screening, diagnosis, and management by primary care clinicians are necessary to prevent adverse chronic kidney disease-associated outcomes, including cardiovascular disease, end-stage kidney disease, and death. Hypertension is possibly the most powerful, modifiable risk factor for the development of heart failure. Chronic hypertension drives cardiac remodeling within the left ventricle resulting in hypertensive heart disease, which ultimately manifests as heart failure. Early detection and appropriate management are necessary to prevent heart failure as well as other cardiovascular diseases.In this case, the patient has multiple health conditions that would benefit from/require dietary management, lifestyle interventions (including exercise) and close medical management. The records do not otherwise indicate that the patient lacks the cognitive faculties, physical capacity or resources to manage his general health conditions in the community. Records indicate that the patient has the cognitive, physical faculties and resources to manage his basic self-care, instrumental activities of daily living, and mobility in the home and community setting. In the long term, the patient is at risk for adverse health outcomes due to his underlying medical conditions, but no substantive and marginal difference in clinical course or outcomes is reasonably expected with the addition of the proposed services over compliantly followed management (e.g., medication intake) of his underlying medical conditions, which the records do not show that he lacks the capacity to execute. Under these circumstances, the requested Community-Based Adult Services (CBAS) non-residential day program is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 parent of a seven-year-old female has requested speech therapy for treatment of her autism.   Findings:  The physician reviewer found that review of the submitted clinical evidence does not demonstrate that the patient made significant progress in speech therapy during the period at issue. Furthermore, the goals outlined are generally considered educational in nature and are not typically treated in the medical system. Speech therapy for these issues is generally directed through an individualized education plan through the education system. There was no medical indication for the therapy at issue.