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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Provigil for treatment of the enrollees post-concussive syndrome.  The physician reviewer found that Provigil is a wake promoting agent that has been approved by the U.S. Food and Drug Administration (FDA) for narcolepsy, obstructive sleep apnea, and shift work sleep disorder. Provigil is currently not approved for children under 18 for any indication. In addition, Provigil has been studied as a treatment for fatigue or excessive sleepiness in a variety of other disorders, such as multiple sclerosis, Parkinsons disease, brain injury and attention deficit hyperactivity disorder (ADHD). Although there are some studies which show that Provigil may be beneficial in treating fatigue or excessive sleepiness associated with traumatic brain injury, these studies are not sufficient to support Provigil as medically necessary for the treatment of this patients condition. In addition, there is a lack of studies which evaluate Provigil for the treatment of sleepiness in children after brain injury. Based on a lack of available data regarding the efficacy and safety of Provigil for the treatment of fatigue or sleepiness, especially in children, Provigil was not and is not medically necessary for this patients condition. Final Result: The reviewer determined that the medication at issue was not and 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 pediatric neurology 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 enrollee requested authorization and coverage for psychotherapy visits at a frequency of every two weeks. The record indicates the enrollee has anxiety, depression, and adjustment disorder and receives treatment with a psychologist every three to four weeks.  She has children with mental health issues and she takes care of her grandchildren.  Notes indicated the enrollee was overwhelmed as her child was in rehabilitation and attempted suicide, which was traumatizing to her and her family.  She has more difficulty navigating things, is not feeling better and verbally lashed out to family as she does not have the reserve to deal with these stressors.  She requested to schedule visits every two weeks rather than every three weeks.  Goals include improving coping skills, self-care, limit setting, boundaries, decreasing symptoms and improving mood.  She wants to continue therapy to be able to take care of herself. According to the medical literature, the core feature in the adjustment disorder diagnosis is clinically significant emotional or behavioral symptoms, as in this enrollee.  Standard treatment for adjustment disorder is psychotherapy to better deal with stressors, decrease symptoms and improve coping skills. This enrollee had reports of ongoing stress contributing to more distress and symptoms. Based on this, she requires more than the every three weeks psychotherapy given and increasing the frequency to every two weeks. The literature indicates that psychotherapy offers significant benefit.  Concerns persist that many adults with depression do not receive treatment that match their level of illness severity. Thus, it is important to strengthen efforts to align depression care with each enrollees clinical needs. This enrollee has been experiencing severe life stressors struggling with ongoing stress and related symptoms. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 83695). In this patients clinical circumstance with a history of hyperlipidemia, Hashimotos thyroiditis, and chronic inflammatory eczema, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations (Stone, et al.; Arnett, et al.). These guidelines do not recommend routine performance of specialized tests in the context of assessing coronary risk, including advanced lipoprotein testing (Stone, et al.). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For these reasons, the advanced lipoprotein testing (CPT 83695) 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 advanced lipoprotein testing (CPT 83695) 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 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 a subspecialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the medication Xiaflex for treatment of his Peyronies disease.  Findings:  Three physician reviewers found that Peyronies disease is caused by scar tissue which forms along the length of the penis in the corpora cavernosa.  Depending on the severity of the condition, this condition can cause penile curvature with erection.  Potential treatments for Peyronies disease include surgery, minimally invasive treatment options and medications.  The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  The only options which have the potential to significantly reduce penile curvature in this patient are Xiaflex injections and reconstructive surgical therapy.  There is sufficient support for the requested medication in this clinical setting.  All told, the requested medication Xiaflex is likely to be of greater benefit than other treatment options. Final Result: Three reviewers determined that the requested medication is 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: All three reviewers are board certified in urology 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: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee requested genetic testing (Pathwork Tissue of Origin Test) for medical evaluation of his malignant neoplasm of the stomach.  Findings:  Two physician reviewers found that the testing was not likely to be more effective for this patient than other available treatment options. The testing is not routine in oncology practices and not clinically indicated in this particular clinical setting. The classification of the patient as having a carcinoma of unknown primary is open to question since histologically and immunohistochemically the findings are consistent with pancreaticobiliary origin. However, with lab and imaging studies, treatment could be planned and administered with this diagnosis alone. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested for a CPM machine for treatment of her frozen shoulder syndrome. Findings:  The physician reviewer found that there is a lack of support in the literature demonstrating that CPM is superior to physical therapy in this patient population, even in the presence of multiple sclerosis.
Appeal type: Urgent Care
Decision: Overturned

A 19-year-old female has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient, a then 18-year-old female, presented to the Emergency Department (ED) complaining of three days of fever with chills, sore throat, and generalized body aches. She did not have a fever in the ED but did have a rapid pulse at 105 and complained of 8/10 throat pain. The patient was seen by a physician who visualized red tonsils coated with exudate. He diagnosed the patient with exudative tonsillitis and treated her in the ED with Motrin, Decadron, and Bicillin. She was discharged from the ED in an improved condition with a prescription for Motrin.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation demonstrates that this patient had a significant bacterial infection of her throat, with the potential for airway compromise. This condition required intervention with an antibiotic. In addition, her pain was severe, documented in the ED as 8 on a scale of 1 to 10. As noted above, severe pain is an appropriate indication for seeking treatment on an emergent basis. All told, a prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention on the date of service in question.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air and associated ground ambulance transportation services. The current practice guidelines emphasize that providers must consider the fragile nature of malnourished patients when determining an appropriate treatment course. The records document that this patient with anorexia nervosa failed to make progress at California facility, and she was referred to the program in Arizona. Although the patients vital signs were stable on transport, she had significant sinus bradycardia and she remained an elevated fall risk during transport. The provider noted that two days prior to transport, the patient had hyponatremia on routine labs. Thus, the patients intake restriction continued to be profound, and she was at risk for a seizure. During transport, the patient required Ativan for anxiety, and she was emotionally distressed throughout most of the trip. Given the patients medical instability, the additional medical monitoring provided via air ambulance transport was medically necessary. For these reasons, the air and associated ground ambulance transportation services were medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

A 37-year-old male has requested Pro-Disc L artificial disc replacement (L4-5) for treatment of his low back pain.  Findings:  Three physician reviewers found that the patient has a history of low back pain.  He has reported intermittent pain down the legs, especially in the right side.  The patient noted balance problems and pain at night.  He reported numbness and tingling in the legs and feet and a sense of weakness in the legs.  Per the patient, sitting, standing, walking, lifting, bending, sneezing, coughing, and twisting exacerbated his pain.  An MRI of the lumbar spine showed mild discogenic disease asymmetric towards the right at L4-5, a 3 to 4 mm focal central protrusion and annular fissure at L4-5 resulting in severe narrowing of the thecal sac, and mild facet arthropathy at L4-5 and L5-S1.   The superior effectiveness of the requested procedure has not been established.  The current medical literature has failed to demonstrate the superior efficacy of artificial disc replacement over lumbar fusion.  Further, the long-term safety has not been demonstrated.  Per the current medical evidence, disc replacement has not proven to be of greater benefit in altering adjacent segment disease as compared to fusion.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of the Inspire device. The Inspire hypoglossal nerve stimulator is approved by the U.S. Food and Drug Administration (FDA) for patients with moderate to severe obstructive sleep apnea (OSA) treatment with an apnea/hypopnea index (AHI) of 15 episodes or more per hour and a BMI less than 35 kg/m2. Hypoglossal nerve stimulator implantation is considered the current standard of care for patients who fail continuous positive airway pressure (CPAP) treatment, as in this patients clinical setting. Hypoglossal nerve stimulator showed significant improvement in treating patients with moderate to severe OSA with improved symptoms and decreased long-term complications from OSA. This patient with severe OSA was found to have an AHI average of 37.1 events per hour. His BMI was documented to be less than 30 kg/m2. As the patient has failed treatment with CPAP therapy as documented in his records, the hypoglossal nerve stimulator implantation is an appropriate treatment modality. All told, the requested implantation of the Inspire device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested implantation of the Inspire device is 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 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology and is 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

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees expressive and receptive language delays. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.   As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, school attainment, and behavior.  These reviewers noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder.  This patient has significant expressive language delay and mild receptive language delay that is significantly impairing his ability to communicate effectively.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional hydrocodone #5 for treatment of the enrollees tooth pain. Findings:  The physician reviewer found that based on the documentation submitted for review, additional hydrocodone #5 has not been established as medically necessary for treatment of the patients medical condition. The medical records show the patient presented with tooth caries, periodontal disease and pain. The patient was given a prescription for Ibuprofen. Ibuprofen is an anti-inflammatory and works to decrease pain and inflammation. Hydrocodone is indicated for acute short-term pain but with high risk of dependence. Opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Based on current medical literature and the presented clinical records, the requested medication 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Elite Seat patient-controlled end range of motion stretching device. Mechanical devices for flexion and extension are recommended as an option in conjunction with continued physical therapy when six weeks of physical therapy alone has been unsuccessful in adequately correcting range of motion limitations secondary to postoperative arthrofibrosis within three months of major knee surgery. The goal is to address specific range of motion limitations that cause functional limitations. In this case, the patient is status post a right anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft in January 2020. At the time of the request for this device, the patient was five months status post ACL surgery. While there are some limited evidenced based indications for this type of device, use is not supported beyond three months after knee surgery. The records do not support that the patient has a diagnosis of arthrofibrosis, which is the primary supported diagnosis for the Elite Seat device. High-quality research is lacking for indications other than postoperative arthrofibrosis. As such, the Elite Seat patient-controlled end range of motion stretching device was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Elite Seat patient-controlled end range of motion stretching device was 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 device at issue was 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 orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for PERFOROMIST (formoterol fumarate) 20 mcg/2 mL inhalation solution. The Health Plan has denied this request indicating that the requested medication solution is not medically necessary for treatment of the enrollees asthma.The medical literature and guidelines do not support the requested medication solution in this clinical setting. PERFOROMIST (formoterol fumarate) nebulized is a long-acting beta-2-adrenergic bronchodilator. The records provided document the severity of the disease and the patients poor control of her asthma. However, there is little support in the medical literature for the efficacy and safety of PERFOROMIST (formoterol fumarate) for the treatment of asthma. Despite this patients poor control of her severe persistent asthma, there is very little evidence that an inhaled long-acting beta-2-adrenergic bronchodilator has any role in the management of her symptoms. Additionally, the use of this agent has not been U.S. Food and Drug Administrative approved for the treatment of asthma. The documentation does not indicate that this patient has been diagnosed with chronic obstructive pulmonary disease or bronchiectasis. Therefore, PERFOROMIST (formoterol fumarate) 20 mcg/2 mL inhalation solution has not been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication solution 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 internal medicine with sub-specialty certification in pulmonary disease and critical care 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.