Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for amphotericin B powder compound vaginal suppository. This patient has been evaluated with multiple cultures, which demonstrated the presence of candida albicans. Per the clinical documentation, she experienced a relief of symptoms with fluconazole with subsequent recurrence. Additional treatment has included voriconazole, which was associated with blurry vision, and posaconazole, which was discontinued due to a lack of efficacy. Multiple vaginal cultures have shown candida albicans with sensitivity to fluconazole. The candida was not sensitive to amphotericin B. There is limited evidence that amphotericin B has been used to some benefit in patients with candida glabrata, but these findings have not been reported in candida albicans. Standard treatment options for recurrent vulvovaginal candidiasis include topical or oral clotrimazole, Miconazole, tioconazole, gentian violet, or boric acid suppositories. There is a lack of documentation that the patient has undergone adequate trials with these conventional therapies. Therefore, the requested amphotericin B powder compound vaginal suppository is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested amphotericin B powder compound vaginal suppository is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for removable foot insert, molded to patient model, longitudinal/metatarsal support (HCPCS code L3020).At issue is whether the removable foot insert, molded to patient model, longitudinal/metatarsal support (HCPCS code L3020) is medically necessary for the treatment of the patients medical condition. For children on Medi-Cal, care is considered medically necessary if it is needed to: (1) prevent disease, disability, and other health conditions or their progression; (2) prolong life; (3) promote physical and mental health and efficiency; or (4) correct or ameliorate any physical or behavioral conditions.According to Carr and colleagues, custom orthotics are used to correct the biomechanical abnormality, reduce loss of medial column of feet when weightbearing, and to allow for pain-free ambulation. In this case, the records document a symptomatic pes planus foot structure along with abnormalities of gait. During the most recent examination, the patient is noted to have foot pain caused by ill-fitting custom orthotics. It is noted that this patients foot has grown considerably since his last pair of orthotics and he needs a new pair of custom orthotics. Therefore, removable foot insert, molded to patient model, longitudinal/metatarsal support (HCPCS code L3020) is medically necessary for treatment of the patients medical condition. Moreover, a new pair of orthotics would correct or ameliorate the patients pes planus.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 podiatry 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 52-year-old male enrollee has requested for a consultation with a neuro-otologist for treatment of her sudden hearing loss. Findings:  The physician reviewer found that there is no tumor, and that the cause for the sudden hearing loss was idiopathic or cause undetermined, though various possibilities have been entertained. The workup the patient has had to date has been medically appropriate and evaluation by a neuro-otologist will not result in any further insight into the cause of the hearing loss than what has already been ascertained.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting Imvexxy 10 MCG (estradiol, vaginal insert) for the treatment of postmenopausal thinning of the vaginal walls (atrophic vaginitis). Vaginal moisturizers have not been effective. The patient tried vaginal estradiol tablets and had a reaction and rash to the medication.  Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. Use of estrogen therapy is appropriate for women with symptoms of vaginal atrophy in the setting of low estrogen levels, provided that there are no contraindications to this therapy (such as certain women with estrogen-dependent tumors). Adequate estrogen therapy leads to restoration of the normal vaginal acidic pH and microflora, thickening of the epithelium, increased vaginal secretions, and decreased vaginal dryness. The agents for vaginal estrogen therapy that are commercially available in the United States are conjugated estrogens (cream) and estradiol (cream, tablet, and ring). A systematic review of 19 randomized trials including over 4000 women that investigated local estrogen treatment found that creams, tablets, and rings were all similarly effective in relieving symptoms of vaginal atrophy. Therefore, Imvexxy (estradiol), a local estrogen therapy, is no more beneficial than the formulary products and there is no medical exception as supported by current medical literature for the requested medication, Imvexxy.  Final Result: The reviewer found that the requested medication is not medically necessary for the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology and 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: Overturned

A 19-year-old female enrollee has requested breast reduction surgery for treatment of her breast asymmetry.  Findings:  The physician reviewer found that in the medical literature, Chen and colleagues noted that obesity is associated with an increased rate of complication. Many of the complications listed can be considered relatively non-major like deformity, delayed wound healing, seroma, infection, and hematoma. Obesity is only a relative contraindication and not an absolute contraindication to performing surgery. It is important to have a thorough discussion with the patient to explain these higher risks, which is documented in the medical records reviewed. Cole and colleagues stated that in two studies measuring quality of life in breast surgical procedures, the subset with a body mass index greater than 30 was as likely to gain as much benefit as other patients with lower or normal body mass index. Nguyen and colleagues concluded that obese women with symptomatic macromastia derive as much benefit from breast reduction as do nonobese women. Thus, even though this patient has a BMI greater than the standard criteria, the requested procedure can improve her quality of life despite the risk of complications. For these reasons, the requested procedure is also medically necessary for treatment of this patients breast asymmetry.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 41-year-old female who has idiopathic thrombocytopenia purpura (ITP). She typically has a platelet count of 50,000 to 65,000 and is appropriately not chronically on therapy. The patient is scheduled for an oophorectomy and her surgeon believes she needs a higher platelet count for the surgery. The patients provider has submitted a request for preoperative treatment with IVIG. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient needs treatment for her ITP prior to surgery to increase her platelet count. In all likelihood, she would not be medically cleared for the operation with a platelet count in the range that is typical for her. IVIG generally works well for the treatment of ITP and would be expected to increase the patients platelet count to a safer level. The Health Plans requirement of a platelet count below 50,000 before IVIG is authorized does not take into account a preoperative situation such as this one. The administration of IVIG to increase the platelet count of a surgical patient with ITP is common practice and consistent with the standard of care. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested physical therapy services for treatment of the enrollees abnormality of gait. Findings:  The physician reviewer found that this patient has been followed for an as-yet undiagnosed neurological condition and abnormal gait, including mild bilateral foot abnormalities and decreased lower extremity strength. While there are no specific studies documenting the utility of physical therapy in a child with this patients particular constellation of physical and functional findings, physical therapy is standard of care for well-defined groups of children exhibiting similar deficits in gait and ambulation. There is sufficient medical evidence supporting the services at issue in this clinical scenario. All told, the physical therapy services at issue were medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 22-year-old female enrollee has requested for hyperbaric oxygen treatment for treatment of her squamous cell carcinoma.   Findings:  Two physician reviewers found that a recent Cochrane Database report analyzing all available evidence for hyperbaric oxygen treatment in patients with late radiation tissue injury concluded that this treatment is associated with improved outcomes in patients with late radiation tissue injury of the head and neck.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old male has requested Aciphex for treatment of his gastroesophageal reflux disease (GERD).   Findings:  The physician reviewer found that the patient has tried and failed several different proton pump inhibitor (PPI) medications, which are on the Health Plans list of preferred PPIs. Many patients respond better to one PPI than any others, as in this patients case. The patients cardiac conditions have been investigated, as well. Therefore, it appears that this patient has attempted to manage his heartburn with other conservative treatment modalities, prior to trying Aciphex. As this patient has not found relief of his symptoms with other PPIs and a trial of Aciphex has been beneficial in the treatment of his symptoms, it is appropriate that the patient be treated with Aciphex.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). The records provided for review document that this patient failed treatment with multiple medications and psychotherapy, and she presents with persistent depressive symptoms. She has been treated with 10 different psychotropic agents from four drug classes including tricyclic antidepressants, selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors. The patients provider has recommended treatment with TMS, which is U.S. Food and Drug Administration (FDA) approved for the treatment of patients in the acute phase of major depressive disorder. Perera and colleagues found that, Daily left prefrontal TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Given the support in the medical literature, the requested TMS is medically necessary for 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 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

The parent of an eight-year-old female has requested Nutropin for treatment of growth hormone deficiency.  Findings:  The physician reviewer found that the patients specialty physician provides results from two stimulation agents, clonidine and L-dopa, each of which shows an insufficient growth response well below 10 ng/mL. A rather low IGF-1 level lends further support to the reliability of the diagnosis of idiopathic growth deficiency. Most important, prior height measurements further confirm the presence of a decreasing height percentile over the last 5 years. An absolute stature below 2.5 SD is not essential for establishing a diagnosis of growth hormone deficiency. The above listed parameters (lack of a sufficient GH response to stimulation, a low IGF-1 level and a subnormal growth velocity) all serve to confirm the medical necessity of replacement growth hormone therapy for this patient. The patients impressive growth response to the initiation of GH therapy further confirms the appropriateness of GH treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female with a history of hypertension, gastroesophageal reflux disease (GERD), allergic rhinitis and chronic sinusitis. She has been maintained on Atacand HCT and Toprol XL for blood pressure control since 2002. There is no documentation indicating treatment with any ACE inhibitor prior to therapy with Atacand HCT. The Health Plan has denied coverage for Atacand HCT.The Health Plans denial should be upheld. There is no medical necessity for treatment with Atacand HCT at this time. The patient has not been tried on an ACE inhibitor and has no known contraindications to ACE inhibitors. Nationally accepted guidelines demonstrate ACE inhibitor therapy is appropriate therapy for the patients hypertension. In addition, records do not demonstrate the patient requires treatment with an angiotensin receptor blocker at this time. Furthermore, the Health Plan indicates if the patient is unable to tolerate treatment with an ACE inhibitor or treatment is ineffective, there are angiotensin receptor blockers other than Atacand HCT available to treat the patients condition. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee requested mental health residential treatment center (RTC) for treatment of the enrollees substance use disorder, anxiety disorder, and unspecified trauma and stressor related disorder.  Findings:  The physician reviewer found that the treatment plan and therapy notes describe her as working with her parents in therapy. Further, she was described as having made a few good relationships and doing very well. She had no health problems and was not receiving any medications. Therefore, this patient would not have met the American Society of Addiction Medicine (ASAM) criteria for RTC level of care on the basis of her alcohol abuse. Moreover, she did not meet the RTC level of care criteria for any comorbid medical condition. There is no evidence that she was a risk to herself or to others, her thoughts were described as linear, her mood was euthymic, and she was not aggressive. The treatment plan does not indicate any medical or nursing care that is being provided. All told, the patient could have been treated at a lower level of care and did not require the intensity or monitoring provided at the RTC level of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for placement of an esophageal stent. A study found that [t]he aim of palliation in patients with inoperable esophageal cancer is to relieve dysphagia with minimal morbidity and mortality, and thus improve quality of life (QOL). The use of [an esophageal stent] is a well-established modality for palliation of dysphagia in such patients. Stent placement is the standard of care for patients with severe dysphagia and a short life expectancy. In this case, the patient has stage IV esophageal cancer. He has been maintained for some time on trastuzumab based on HER2 amplification in the adenocarcinoma. Thus far, there has been no progression but he has had intermittent, severe dysphagia. This clinical situation is common with this disease and patients need frequent intervention from gastroenterologists to open the esophageal lumen. The patient previously had a stent placed on two occasions but each time the stent migrated. The new stenting proposed for this patient is the standard care and is medically necessary and appropriate.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 internal medicine with subspecialty certificates in medical oncology and hematology, 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 LORETA neurofeedback therapy two to three times per week for six months. The records provided for review document that this patient has a history of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) with problems in memory, concentration, and hyperarousal symptoms due to traumatic cues associated with his assault. The patient has a complex psychiatric and neurological presentation. He has been treated with various psychotherapeutic  and psychopharmacological approaches without substantial improvement. The best outcome for the patients psychiatric and neurological symptoms has been from LORETA neurofeedback. As noted in the medical literature, one of the best indicators for future benefit in a patient is past positive response to a treatment modality. In addition, systematic reviews report low risk and high value patient health outcomes with neurofeedback in the treatment of patients with TBI and PTSD (Reiter, et al.; Panisch and Hai). For these reasons, the requested LORETA neurofeedback therapy two to three times per week for six months is medically necessary for 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 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

A 63-year-old male enrollee has requested for bilateral digital hearing aids for treatment of his hearing loss. Findings:  The physician reviewer found that digital signal processing allows manufacturers to create hearing aids with enhanced processing and features. Current digital hearing aids use this capability to perform loudness growth and threshold testing in order to obtain fitting information specific to an individual patient's ears.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene expression classifier for the evaluation of his indeterminate thyroid nodules. Findings:  Three physician reviewers found that Fine Needle Aspiration (FNA) is a well established procedure in determining if a thyroid nodule is malignant or benign with good sensitivity for a papillary thyroid cancer. This testing is supposed to help in planning future intervention. The negative predictive value is higher in this test but the literature has shown that the positive predictive value is low. The Afirma gene expression classifier potentially can improve the net health outcome by providing an alternative to diagnostic thyroid surgery. While there is some support for its use in this clinical setting, there is still insufficient data to confirm the superior efficacy of this testing over Fine Needle Aspiration (FNA). As such, long-term outcome data is still needed to support clinical and histologic outcomes. In this patients case, when the initial cytopathology was indeterminate, a repeat Fine Needle Aspiration (FNA) had been sent for cytopathology was interpreted as benign. In sum, due to insufficient long-term outcome data as well as the clinical documentation, the gene testing performed was not likely to have been more beneficial than the available standard. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.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.