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

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for Absorica 25 mg tablet, once a day. A high-fat meal is needed for optimal absorption of isotretinoin. Absorica, isotretinoin-Lidose, is a specialized formulation of isotretinoin that enhances absorption of isotretinoin in the absence of dietary fat and may be used with patients who are unable to take medication with food. Vegetarianism in and of itself is not a medical indication for the use of Absorica, as there are non-meat alternatives with high fat content, including nuts and oils. In this case, the use of isotretinoin-Lidose is not medically indicated over the use of isotretinoin. Therefore, Absorica 25 mg tablet, once a day is 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 dermatology 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:  An enrollee has requested lorazepam for treatment of her behavioral health condition. Findings:  The physician reviewer found that the medical records submitted for review does not support the medical necessity for the requested medication. There is a lack of longitudinal history detailing the illness burden or interventions tried and failed. It is unclear if lorazepam, which is potentially unique from the formulary equivalents as it bypasses phase I hepatic metabolism and has a relatively delayed onset of action with no active metabolites, had been prescribed previously. Moreover, based on the documentation submitted for review, it is not possible to assert with any degree of certainty that lorazepam would be significantly more effective and/or better tolerated than the two formulary alternatives, diazepam and alprazolam. Thus, based on the documentation provided, the requested medication is not medically necessary. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether apolipoprotein assay (CPT code 82172) performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. The records documented a diagnosis of lung cancer. The provider documented concern for metastasis to the liver.Findings:  Three physician reviewers found that there is very little data relating this assay to the treatment or prognosis of cancer. Apolipoprotein levels have been studied for their relationship and prognostic ability for cerebrovascular accident (CVA), atherosclerosis, and myocardial infarction.   It is not clear why this test was ordered during the workup of possible liver metastases. Therefore, apolipoprotein assay (CPT code 82172) performed was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test was not likely to be more beneficial for evaluation 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 sub-specialty certification in medical oncology, 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a left high condylar shave as a component of the approved corrective jaw surgery. Disturbances in the growth pattern of the mandibular condyle during the normal growth period may result in condylar hyperplasia and is diagnosed by bone scan. Abu Arqub and colleagues report that condylar hyperplasia is one of the causes of asymmetric facial growth resulting from overgrowth or hyperactivity in the mandibular condyles and that treatment of malocclusion secondary to condylar hyperplasia may involve orthognathic surgery and condylar surgery if the condyle shows hyperactivity. In this case, given that the patients malocclusion is a skeletal deformity that is the result of left condylar hyperplasia, creating a left-side cross bite, mandibular asymmetry, and transverse maxillary deficiency, and as a bone scan showed the hyperactivity of the left condyle, the requested service is medically indicated. Thus, a left high condylar shave as a component of the approved corrective jaw surgery is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, there is an abnormal structure of the body, as the patients condylar hyperplasia resulted in mandibular asymmetry, class III malocclusion, and canted maxilla. Condylar hyperplasia is a developmental abnormality secondary to disturbances in the growth pattern of mandibular condyle during the growth period. The requested orthognathic surgery will correct the patients occlusion and mandibular asymmetry, and the TMJ surgery will cease the patients condylar growth and prevent future relapse. The proposed surgery will definitely change both the patient's facial appearance and craniofacial function. Thus, the requested procedure is being performed to improve function and to create a more than minimal improvement in the patients appearance. For these reasons, a left high condylar shave (as a component of the approved corrective jaw surgery is reconstructive in nature for this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings: The physician reviewers found that the residential treatment center services provided were and are medically necessary for treatment of the patients medical condition. The patient appears to be very fragile. The patients main stressor is dealing with peers in the school setting. The patient has had very little experience outside the residential treatment center level of care to gauge his reactions to the normal stressors of his home environment. As confirmed, by details provided by the patients parent, he is not yet ready for discharge to a lower level of care. The patient is not equipped to handle these stressors and would likely decompensate when expected to do so. Discharge at this time would likely require re-admittance to an acute care facility, thus undoing the gains the patient has made so far. This patient needs to continue in the residential treatment program in order to solidify his gains and slowly transition back home without fear of regression and relapse. Given the above, the services at issue were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewersdetermined 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 physician 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hearing aids with masking sounds. Recent literature explains that tinnitus is the perception of phantom sound in the absence of a corresponding external source. It is a highly prevalent disorder, and most cases are caused by cochlear injury that leads to peripheral deafferentation, which results in adaptive changes in the CNS. Tinnitus is a heterogeneous disorder, tinnitus sound can differ between individuals, it can result from many different types of injury and its effect can vary from a minor annoyance to catastrophic impact on daily life. Current tinnitus management options include hearing aids, sound generators, cognitive behavioral therapy (CBT), music therapy, tinnitus retraining therapy (TRT), relaxation therapy, or may involve pharmacotherapy for associated problems such as insomnia, anxiety, or depression. Masking can be used to totally or partially reduce the audibility of tinnitus by covering it with another sound. An increased benefit derived from maskers has been demonstrated in patients with tinnitus. In this patient with sensorineural hearing loss and tinnitus, hearing aids with masking is medically necessary. Final Result: The physician reviewer determined that the requested devices are medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in otolaryngology 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 Epclusa for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the 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 recommendations apply regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive, genotype 3 patients.  This is based on the ASTRAL-3 trial for Epclusa, which showed a 98% cure rate (Foster, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C virus.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: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested Alimta (with carboplatin) for treatment of pleural mesothelioma.  Findings:  Three physician reviewers found that there has been ample documentation in the literature of the usefulness of Alimta when given in combination with carboplatin in the treatment of malignant mesothelioma. Indeed, many oncologists use this carboplatin/ Alimta combination as first-line therapy. The proposed treatment regimen is no longer considered investigational as the medical benefit has been clearly established.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested intensive outpatient program services for the treatment of her depression, anxiety and self-destructive behaviors. Findings:  The physician reviewer found that this patient underwent intensive outpatient treatment during the dates in question. The basis for this treatment is not clearly defined. The submitted documentation does not include a detailed account of her present illness. She may have also been receiving medications concurrent with her intensive outpatient treatment. This was mentioned in the initial treatment plan, but not subsequently. All told, the submitted documentation does not demonstrate the medical necessity of the treatment rendered. While the records do describe certain symptoms including the possible use of drugs, depression, anxiety and past self-harming behaviors, the statements describing these symptoms are often vague and non-specific. The need for treatment was not delineated or defined. Nor is there evidence that the patient was progressing with treatment. Intensive outpatient treatment was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested cognitive behavioral therapy (CBT-I) for treatment of her insomnia. Findings:  The physician reviewer found that CBT-I is an accepted therapy for insomnia and is the standard of treatment according to the American Academy of Sleep Medicine. Compared to hypnotic therapy, CBT-I results in longer-sustained effects. Although many providers can be trained in treating insomnia, the provider should have specific training in CBT-I. In this case, the Health Plan does not contract with a CBT-I trained provider, and therefore, sessions with an out-of-network CBT-I-trained provider are medically reasonable and necessary.  Therefore, CBTI is clinically indicated for this patient. Final Result: The reviewersdetermined 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 physician reviewer is board certified in sleep 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: Upheld

A 26-year-old female enrollee has requested for emergency services request indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that the patient who presented to the emergency department complaining of a sore throat. The patients presenting symptoms and physical examination do not reveal anything that could be considered an emergency. With the wide availability of information about pharyngitis and the frequent occurrence of sore throat, a prudent layperson would not reasonably expect the absence of emergency care to jeopardize his or her health in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested lumbar spine fusion for treatment of his chronic low back pain and radiculopathy of the left lower extremity.  Findings:  The physician reviewer found that there is no evidence of instability, angulation, significant scoliosis, spondylolysis, spondylolisthesis, trauma, or infection in this patients records, all of which would be considered criteria for spinal fusion. Thus, the proposed two level spinal fusion is not considered medically necessary and is not indicated in the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old male with a prolactin-secreting macroadenoma who is status post trans-sphenoidal resection several years ago. He has a residual tumor measuring 2.7cm in size with no apparent increase in size since the surgery. He is taking Dostinex 2mg twice a week to control prolactin secretion.  The patients prolactin level was 242 in June 2004. His prolactin level rose to 376 in November 2004 possibly due to non-compliance in taking the Dostinex as prescribed. The patients prolactin level dropped to 189 in March 2005 but rose again to 294.8 in August 2005 and 346.6 in November 2005. The patient was found to have blurriness in his right eye and galactorrhea when last seen by his endocrinologist. The treating physician recommended increasing Dostinex to 2mg three times a week and referred him for visual field testing.  The Health Plan has denied the patients request for Dostinex 2mg three times per week based upon medical necessity and has indicated it will not continue to authorize the medication at a frequency greater than once per week.This patient has fluctuating prolactin levels. His highest level of 376 in November 2004 was probably due to non-compliance. In March 2005 his level dropped to 189, which appears to be his baseline according to the treating physicians notes. Although the patient has a large residual tumor it has not grown and is unlikely to be the cause of his high prolactin level in November 2005. Because of the large residual tumor Dostinex should be continued at 2mg twice weekly for an additional 12 months. If the dosage is decreased to 1mg twice per week before the reason for the high prolactin levels is clear, it will introduce an additional variable and confound the clinical evaluation.  The treating physician should closely monitor compliance during the next 12-month period so that non-compliance can be ruled out as the cause of the recently high prolactin levels.  If the patients prolactin level returns to his baseline at this dosage and he can be maintained at the lower level, a cautious trial of 1mg twice per week would be indicated.  If the prolactin level continues to rise or if a visual field defect is present, the patient should continue at the dosage of 2mg twice per week and be referred for the appropriate neurosurgical evaluation.Based upon the information set forth above, I have determined although the requested dosage of Dostinex 2mg three times per week is not medically necessary for treatment of the patients medical condition, Dostinex 2mg twice per week is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested Vicodin for treatment of his pain.  Findings:  The physician reviewer found that based upon the submitted documentation, the patient has not seen an ear nose and throat specialist for his sinus troubles, a headache specialist for his migraines, or an interventional pain physician or acupuncturist for his neck pain. In the case of frequent headaches, abortive therapy should only consist of narcotic sparingly, as frequent use can cause rebound headache and dependence.  A good prophylactic and abortive migraine program with a trained headache specialist would be much more beneficial.  The use of a short-acting narcotic such as Vicodin should only be done at the discretion of his physician for severe unremitting pain due to a well-defined pain source. All told, in this patients case, the requested Vicodin is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) (77059 and A9579) with computer aided detection (0159T) for evaluation of her history of bloody nipple discharge and a family history of breast cancer.  Findings:  Two physician reviewers found that in this patients case, the bilateral breast MRI with computer aided detection performed on the date specified was likely to have been superior over other available methods of evaluation.  The current medical evidence supports the diagnostic procedure at issue in this clinical setting.  She has a strong family history of breast cancer.  The patient has very dense breasts on mammogram, and this may lower the sensitivity of mammography.  The records document recurrent blood nipple discharge status post right breast duct excisional biopsy.  In this case, the diagnostic procedure at issue was likely to have been more effective than other modalities for evaluation this patients condition.