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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Victoza Pen injections, one injection daily for treatment of her type 2 diabetes.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. Victoza and Bydureon are a members of the glucagon-like peptide 1 (GLP-1) analogues, a relatively new class of incretin-based therapies used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Another important possible additional beneficial of these medications relates to potential improvements in beta cell function. All of the GLP-1 analogue therapies have been associated with significant glycemic control to date. In this case, because the patient is doing well on Victoza she will likely benefit from Bydureon as well. Given the reasons provided above, Victoza is not medically necessary for treatment of the patients medical condition. 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 endocrinology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center from 11/1/16 forward. Findings:  The physician reviewer found that the patient had finished detoxification and did not have any severe acute post withdrawal symptoms. There was no evidence that on 10/31/16 the patient had any suicidal or homicidal thoughts. The patient did not have any mania or psychosis. The patient was calm and cooperative with treatment. She did not have any aggression and was compliant with her medications. She did not have any medical problems that would require 24-hour care. She was able to perform her activities of daily living. There is a chronic risk for relapse, but she had progressed enough to be treated in a lower level of care and no longer required 24-hour supervision. In group therapy notes, the patient reports that she feels that she is able resist temptations to use substances. The patient does have some ambivalence about behavior change, but she no longer requires 24-hour supervision. The patient continues to require treatment for her substance use problems, but the patient has improved enough to be discharged to a less restrictive environment such as a partial hospitalization program. Final Result: The reviewer determined that services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 five-year-old female has requested coverage for group speech therapy services in a group of at least three children for treatment of her autism.  Findings:  The physician reviewer found that the patient is currently receiving one hour weekly of individual speech therapy. In addition to the individual speech therapy, the patients parent has requested group speech therapy in a group of at least three children. The requested group speech therapy would be considered an adjunctive therapy for the patient, as socialization and pragmatic speech would be the goals involved in group speech therapy. Although, the medical literature supports speech therapy in the autistic population, there is no evidence in the peer reviewed medical literature indicating that speech therapy provided in a group setting augments individual speech therapy. In this case, the patients parent has requested coverage for group speech therapy in a group of at least three children. There is no scientific data demonstrating that the requested service results in improved outcomes in this patient population as opposed to individual speech therapy alone. As there is no evidence in the available peer reviewed medical literature establishing the value of combining both group and individual speech therapy in the treatment of autistic patients, the Health Plans denial of the requested group speech therapy as not medically necessary was appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Applying the ASAM guidelines, the patient was not in substantial withdrawal-related distress. The reported CIWA scores represented mild objective withdrawal related distress. The patient did not have any reported biomedical condition that distracts from recovery. The provider reported that the patient has sufficient mental status to permit participation in treatment. According to the records, the patient had no acute symptoms from a substance use disorder, exhibited limited functional impairment, was free of suicidal ideation, and was compliant with his psychiatric medication regimen. The patient has demonstrated limited understanding of his substance use on coping and functioning. He has displayed motivation to change and an interest in continuing outpatient treatment. The provider described the patient as active in all therapy groups. The patient remains at risk for relapse as he is experiencing addiction symptoms including craving and urges to use substances. Given these findings, the patient meets two of the required six criterion for RTC level of care. Therefore, the RTC level of care services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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 authorization and coverage for osteochondral allograft transplant treatment of the enrollees knee pain. Findings: Three physician reviewers found that this patient presents with persistent significant right knee pain and swelling. Functional difficulty is documented in activities beyond basic activities of daily living. Clinical examination findings are consistent with imaging evidence of a large osteochondral lesion, measuring well over 4 square centimeters, of the medial femoral condyle. He was status post multiple ACL reconstruction procedures, with the treating provider reporting the current ACL deficiency is correctable. There was mild to moderate medial joint space narrowing documented with neutral alignment. Evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. This request for osteochondral allograft (OCA) transplantation has been recommended as an option to avoid total knee replacement given the patients young age. There is peer-reviewed literature support for OCA transplantation in this situation. Therefore, the requested osteochondral allograft transplant is likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewer are 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

Findings:  Medical literature supports that the requested device is medically necessary. Studies concluded that the adjunctive use of pulsed electromagnetic field (PEMF) for fifth metatarsal fracture non-unions produced a significant increase in local placental growth factor. PEMF also produced trends toward higher levels of multiple other factors and faster average time to radiographic union compared to unstimulated controls. Their study included patients who had been diagnosed with a fifth metatarsal fracture with delayed or non-union, with no progressive signs of healing for a minimum of three months. Shi and colleagues concluded that long-bone fracture patients treated with an early application of PEMF achieved a significantly increased rate of union and an overall reduced suffering time compared with patients that receive PEMF after six months or more of delayed union.In this case, the submitted documentation reflects that the patient has persistent right foot pain and has been diagnosed with a non-displaced right fifth metatarsal fracture non-union following a traumatic injury to the right foot. She has been immobilized in a CAM walker. Serial follow-up x-rays have documented no significant fracture healing. Current evidence based medical literature supports the use of this type of bone stimulation for fifth metatarsal fracture non-unions as safe and effective. Therefore, the requested electromagnetic bone growth stimulator device is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested device 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 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: Overturned

A 28-year-old female enrollee has requested laparoscopic duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that the laparoscopic duodenal switch bariatric surgical procedure has not been shown to have a higher complication rate than other weight loss surgical procedures. Gastric bypass operation is frequently associated with dumping syndrome, marginal ulcers, weight regain and inadequate weight loss, amongst other complications. The Roux-en-Y procedure has been associated with malabsorption and nutritional deficiencies. In addition, this patient would not be able to take NSAIDS. While gastric banding would allow the patient to take NSAIDS, it is associated with lower percentages of excess weight loss following the procedure, and she may not be able to lose sufficient weight with that procedure. The reference cited above does not identify a significant incidence of adverse effects with the duodenal switch compared with gastric bypass and confirms the higher percentages of excess body weight loss in patients with the duodenal switch, as compared with gastric banding. Given the patient's weight and comorbidities, the duodenal switch procedure is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tandem T:Slim X2 Insulin Pump.Insulin pump technologies have advanced dramatically in the last several years to integrate with continuous glucose monitors (CGM) and incorporate control algorithms. The Medtronic MiniMed 670G system was the first commercially available hybrid closed-loop system (HCL). It uses the MiniMed 670G insulin pump, the Guardian 3 CGM glucose sensor, and a modified proportionalintegralderivative (PID) algorithm called SmartGuard technology. According to Saunders and colleagues, the MiniMed 670G system responds to the sensor glucose value and automatically adjusts basal insulin delivery every five minutes by either increasing, decreasing, or suspending insulin delivery. The T:Slim, unlike the 670G, is a newer closed loop system which uses the Control-IQ system to incorporate a factory-calibrated CGM and automated correction boluses, in addition to automated basal delivery, to improve benefit and reduce burden. A recent study by Brown and colleagues demonstrated lower glycemic variability and greater percentage of time in target range for patients using this system versus a hybrid closed loop. In this case, the patient has had extreme glycemic variability with his current insulin pump and sensor. Therefore, Tandem T:Slim X2 Insulin Pump is medically necessary for the treatment of the patients medical condition.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

The parent of a nine-year-old male enrollee has requested growth hormone therapy for the treatment of idiopathic short stature. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient fulfils the Food and Drug Administration criteria for growth hormone therapy for idiopathic short stature, as he is abnormally short, and has a projected short adult height, which is well below his mid-parental target. Additional clinical support comes from a low IGF-1 level and a good growth response to previous treatment with growth hormone therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a WalkAide foot drop system.The requested WalkAide foot drop system is not medically necessary for treatment of this patients medical condition. Additional prospective clinical studies of the WalkAide device are necessary to evaluate whether it improves function and reduces disability compared to standard bracing in persons with foot drop (Miller, et al.; and Everaert, et al.).In this case, the WalkAide foot drop system has been requested to treat a patient with foot drop after a cerebrovascular accident. There is currently insufficient evidence to support the use of the requested WalkAide device for foot drop and other indications. Accordingly, the requested WalkAide foot drop system is not medically necessary for treatment of the patient's medical condition at this time.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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: Upheld

A 73-year-old male enrollee requested chemotherapy with Erbitux (cetuximab) shots for medical treatment of his lung cancer.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available treatment options. The medical literature supporting cetuximab as a second-line therapy are not convincing as the numbers are small and overall survival benefits are limited. Moreover, Sgambato and colleagues noted that the U.S. Food and Drug Administration (FDA) rejected cetuximab in combination with chemotherapy as a first-line therapy of advanced non-small cell lung cancer (NSCLC). In addition, there are multiple chemotherapy options available to treat lung cancer as a second-line therapy. Therefore, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male has requested approval for radiofrequency ablation of the sacroiliac (SI) joints and lateral branch nerves for treatment of his bilateral SI joint dysfunction.   Findings:  Two physician reviewers found that the patient has a history of back and buttock pain and anterior thigh numbness. The patient is noted to be status post fusion. A computed tomography (CT) guided medial branch injection demonstrated mild bilateral anterior lipping at the SI joints with mild scoliosis on the iliac side of the SI joint bilaterally. The patients diagnosis was bilateral sacroiliac (SI) joint dysfunction. The providers notes document great relief from bilateral SI joint intra-articular injections with recurrence of pain. The patients medications include Norco 1-2 pills as needed, Gabapentin 3600mg, and Baclofen 5mg three times per day. The patient is being tapered off Baclofen due to side effects and is planned to start Cymbalta. The patient has also been treated with Naproxen and Diclofenac. The provider has recommended radiofrequency ablation (RFA) of the SI joints.  There is inadequate clinical evidence to demonstrate that the radiofrequency ablation of the SI joint is likely to be more beneficial compared to standard treatments for SI related pain. As noted by Rupert and colleagues, the limitations of this systematic review include the paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodological flaws. The authors concluded that the indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. Overall, the requested radiofrequency ablation is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old woman who had a benign dermatofibroma of the right calf removed in June 2005. She was concerned about the appearance of the scar two to three months after the procedure.  The patient requested a scar revision, which the Health Plan has denied as not medically necessary.Reviewed are the records of the patient, which include her initial dermatological evaluation, operative procedure note, pathology report, and follow-up evaluation by her surgeon (photographs not provided). All records concern the removal of a benign dermatofibroma of the right calf and the resulting scar, which measured 1.5 cm x 1.0 cm x 0.5 cm. Scars in this area of the body can take upwards of eighteen months to reach maturity and to lose their excess bulk and pronounced color. Thus, the patient is not an appropriate candidate for scar revision at this time. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement for emergency services provided on 4/25/16. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The emergency department services provided on 4/25/16 were necessary for treatment of an emergency medical condition. According to the documentation submitted for review, the patient presented with ear pain, crying and in distress. There are several entities which may present with persistent and worsening ear pain, including otitis externa, otitis media, perforation of the tympanic membrane, malignant otitis, and mastoiditis, as well as referred pain from the jaw or teeth. Otitis externa is the most benign of these conditions, and the presence or absence of a fever cannot reliably rule any of the complications in or out. The differentiation requires a thorough ear, nose, and throat exam. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested M300 group 3 power wheelchair for treatment of her diagnosis of obesity, chronic pain and lipolymphedema.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The records indicate that she has good to good plus strength in the upper limbs, fair minus to good strength in the lower limbs, and no functional range of motion deficits in the limbs that would preclude household mobility with an optimally fit manual wheelchair using her upper and lower limbs for bimanual and bipedal propulsion. Regular use of a power mobility device would further decrease her physical activity levels and exercise and would be expected to worsen her health conditions in the long-term.  Additionally, her home is not fully accessible to a power mobility device.  All told, the requested M300 group 3 power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-nine year-old male who has a history of asthma and allergic rhinitis is requesting for authorization and coverage for Xolair.  Reviewers Findings:  The reviewing physician found that the patients IgE level is elevated beyond the scope of approval of Xolair.  The reviewing physician found that the Health Plan denial should be upheld.