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

The parent of an 18-year-old female enrollee has requested long-term in home licensed vocational nurse (LVN) nursing care for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. This patient presents with cerebral palsy and multiple sequelae, including poor airway protection, ADHD, anxiety/panic attacks, and dysphagia necessitating gastrostomy tube feedings. These medical conditions mandate constant skilled supervision with expertise to provide timely intervention. She is dependent for airway clearance, requiring direction for self-suctioning during the day and caregiver suctioning while she sleeps (approximately 10 hours each night). She must be monitored for aspiration events, with skilled interventions if necessary, such as chest physiotherapy, breathing treatments, and supplemental oxygen. Her ability to perform activities of daily living is severely limited by her diagnoses, and she requires support in all areas in order to maintain health and well-being. The mother recently passed away, and the father is a full-time professional that is unable to provide her care at home. Therefore, the patient requires trained nursing to maintain airway clearance, with the goal of preventing future episodes of aspiration pneumonia, respiratory distress syndrome, and need for tracheostomy. Further, she needs to be monitored for anxiety so that timely intervention is possible. Therefore, long-term in home licensed vocational nurse (LVN) nursing care is medically necessary and appropriate. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

The representative of a now deceased female enrollee has requested reimbursement for medical services for treatment of the enrollees sudden hepatic failure, breast cancer with multiple metastases and electrolyte imbalance. Findings:  The physician reviewer found that the patient was seeking possible alternative treatment, but she deteriorated quickly and received standard emergency care just prior to her death.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested neuropsychological testing for evaluation of his status post concussion.  Findings:  The physician reviewer found that neuropsychological assessment shows good clinical utility in the diagnosis and management of concussion.  This post-concussive patient had received treatment but remained symptomatic.  In such circumstances, neuropsychological evaluation is supported by current practice standards and clinical guidelines.  The current medical evidence supports neuropsychological assessment for patients with cognitive symptoms which are refractory to treatment.  There is sufficient support for the services at issue in this clinical setting.  All told, neuropsychological testing provided during the time frame specified was medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested Xenazine (tetrabenazine) for treatment of his Huntingtons disease.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Xenazine is the standard of care for treating chorea in Huntingtons disease and the U.S. Food and Drug Administration approved Xenazine for that indication. This patient has a diagnosis of Huntingtons disease and has documented failure of risperidone and his neurologist reports that he previously tried and failed Haldol. This patient has severe chorea affecting his activities of daily living including the ability to feed himself. In addition, this patient has been gradually titrated to an appropriate dose of Xenazine by his neurologist. For the reasons set forth above, Xenazine is approved in this clinical setting and is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation (RFA) of the left and right first and second perforator veins (CPT 36475 x 2 and/or CPT 36476 x 2). The documentation provided for review does not support the medical necessity of the requested perforator vein treatments (Erben, et al.; Ozkan). Obi and colleagues noted that varicose vein surgery is predominantly characterized by endovenous treatment of axial vein reflux, phlebectomy of clusters, and substantial improvement in Venous Clinical Severity Scores. However, in this patients case, there is a lack of evidence of ulceration to support an indication for perforator vein treatment. In addition, there is a lack of report that evaluation with an arterial perfusion study was performed given the patients complaints of leg pain aggravated by walking. Furthermore, the records do not report that the patient has attempted an adequate trial of treatment with a lymphedema compression pump. Given these findings, the requested radiofrequency ablation (RFA) of the left and right first and second perforator veins (CPT 36475 x 2 and CPT 36476 x 2) is 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 general surgery with subspecialty certification in vascular 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 parent of a 17-year-old male enrollee has requested for continued adolescent mental health inpatient treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that this patient has recently failed less restrictive treatments and continues to experience severely disabling depressive symptoms. His symptom severity does not allow him to fully cooperate with his treatment in the hospital, and he would most likely deteriorate in a less restrictive setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Enteric Pathogens Panel. The American Academy of Family Practice guidelines for the evaluation of acute diarrhea do not recommend the use of polymerase chain reaction (PCR) assays. These tests do not discriminate between viable and non-viable organisms and can detect microbes at nonpathogenic levels. Given the high rates of asymptomatic carriage of enteropathogens, this can be a considerable problem. Moreover, the relative importance of each pathogen may be unclear. Per the guidelines from the Infectious Diseases Society of America (IDSA), a gastrointestinal pathogen panel is not recommended in cases of diarrhea without complications such as fever or hematochezia. This patient presented with diarrhea without complications such as fever or hematochezia. Evaluation for parasites and Clostridium difficile in May 2020 at the onset of her symptoms were negative. Thus, the Enteric Pathogens Panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Enteric Pathogens Panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested Gilenya for treatment of her relapsing-remitting multiple sclerosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has relapsing-remitting MS, which is very active with multiple exacerbations over the last two years. She has been treated for several years with Rebif, but continued to have exacerbations. The medical literature shows that Copaxone and interferons have similar overall efficacy in reducing the frequency of exacerbations. Treatment options for very clinically active MS include Tysabri, fingolimod (Gilenya), and other new oral agents. A recent review noted that Gilenya is the first oral treatment of MS and has recently been approved as single disease-modifying therapy in highly active relapsing-remitting multiple sclerosis for adult patients with high disease activity despite basic treatment. In addition, Cohen and colleagues reported that Gilenya showed greater efficacy than intramuscular interferon beta-1a in patients with relapsing-remitting multiple sclerosis. This patient has clinically active MS, and requires treatment more effective than basic platform therapy. Therefore, Gilenya, which is more effective than Copaxone or beta interferon, is appropriate and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for eight weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, the requested medication regimen is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers and diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: Two of three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting coverage for Emergency Room (ER) services. The Health Plan denied the request as the services provided were not emergency medical services.Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition is 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 placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.In this case, the patient did not have an emergency medical condition. She did not have severe acute symptoms that placed her health in serious jeopardy. The patients condition also did not put her at risk for serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The patients symptoms had been present for two weeks. She had stable vital signs and was noted to be in no distress. Her examination was typical of arthritis without additional evidence of any serious complication, infection, or other medical emergency. The patients condition could have been treated appropriately and safely in a lower acuity setting such as an urgent care or primary care clinic. Since the patient did not have an emergency medical condition, the services provided were not emergency medical services.Final Result: The reviewer determined that the requested services at issue were not emergency medical services. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing. Findings:  The physician reviewers found that the medical evidence supports the services at issue in this patients case.  The cytopathology of the 2 cm thyroid nodule was consistent with follicular lesion of undetermined significance.  The risk of malignancy is 5% to 15% in these nodules.  The newest 2015 American Thyroid Association guidelines state that for nodules with follicular lesion of undetermined significance cytology, molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery.  The American Thyroid Association also recommends taking the patients history, ultrasound appearance and other clinical factors in consideration in order to make medical and surgical decisions.  In this patients case, Afirma Gene Expression Classifier testing performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 3 of 3 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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The patient is a 46-year-old woman who underwent gastric bypass in 2004 and has since had a considerable weight loss.  She has excess skin in the abdominal area and a panniculus.  Reports of back pain and skin irritation related to her condition are noted in the record. The patient has requested authorization for abdominoplasty and panniculectomy.  The Health Plan has denied her request based upon a determination that the surgical procedures are not medically necessary.  The records provided document a weight maximum of 216 pounds in May 2004 pre-bypass and a weight minimum of 124 pounds in September 2005, which indicates a documented loss of 92 pounds. However, the Health Plans requirement of a 100-pound weight loss should not be considered the primary reason for denial of the requested surgery. The Health Plan also requires that the panniculus hang at or below the level of the pubis.  This criterion is not met as photographs show that the hanging skin does not even reach the pubis, and there appears to be more lateral, rather than midline draping.  Photographic evidence of a chronic recurring skin condition refractory to appropriate medical therapy is also required. There are no photographs presented showing any irregularity of her abdominal skin and, there are no doctors notes recording treatments related to an on-going skin condition. Based on the photographic evidence and the lack of any demonstratable complaint related to her pannus, I have determined the requested procedures are cosmetic and not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested Avodart for the treatment of his urinary retention. Findings:  The physician reviewer found that Proscar and Avodart are both recognized to improve benign prostatic hypertrophy symptoms, decrease prostate volume and improve both objective and subjective symptoms. While there are some mild differences between the drugs, practical differences that translate into clinical differences have not been proven. The American Urology Association Benign Prostate Hypertrophy guidelines do show that both of these medications show improvement over placebo. The Health Plans requirement that the patient take Proscar is medically reasonable.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to the usual screening views has been widely accepted by radiologists due to the associated decreased callback rate and increased detection of smaller cancers.  This technique has proven especially valuable in patients with extremely dense tissue, as in this patients case.  All told, the addition of tomosynthesis to the usual screening protocol was likely to have been of greater benefit to the patient than digital mammography alone.  Therefore, the submitted documentation supports the superior efficacy of the breast tomosynthesis.  Final Result: Three 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient was showing mild post-acute withdrawal symptoms.  He was not a danger to himself or others, and was not having self-harming urges.  He was medically stable. His general anxiety disorder was not out of control, and he did not require a confined and structured setting. He was engaged and working the program. He knew his triggers and was well versed in steps. He was utilizing meditation and mindfulness techniques.  Naltrexone was restarted on 6/21/17.  In groups, he demonstrated a good understanding of the 12-step program evidenced by his ability to describe and explain steps 8 and 9 to others based on prior work with his sponsor.  He denied suicidal or homicidal ideation.  His pulse was 110, blood pressure 132.97.  Medications included Cymbalta and Clonidine.  He had found a sober living environment and planned to start hepatitis C treatment.  He was sent to the emergency department due to an episode of palpitations and shortness of breath. His pulse was 132. His tachycardia, future hepatitis C treatment, and naltrexone/Vivitrol could have been managed on an outpatient basis. He no longer required 24 hours per day, 7 days a week supervision, and could have been stepped down to an ambulatory level of care. In sum, residential treatment care was not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 sub-specialty certification in addiction 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.