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

Physician 1: The patient is a 33-year-old female with degenerative disc disease. She has had a positive discogram at L4-5 and L5-S1. She is status post laminectomy and discectomy at L4-5. Her provider is recommending two-level artificial disc replacement at levels L4-5 and L5-S1. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. There is no evidence supporting the safety and efficacy of a two-level disc replacement. Accordingly, I have determined the requested procedure 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.Physician 2: The patient is a 33-year-old female with back pain. An MRI revealed disc protrusion at L4-5 and L5-S1 as well as degenerative changes at L3-4. Her physician has recommended multi-level artificial disc replacement at L4-5 and L5-S1. The Health Plan indicates the efficacy of artificial disc replacement has not been established.Artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 33-year-old female who has degenerative disc disease at L4-5 and L5-S1. Conservative treatment modalities have not been effective. Her physician has recommended two-level artificial disc replacement surgery. The Health Plan has denied authorization for the requested procedure citing the lack of proven efficacy.Artificial disc replacement is experimental without established long-term safety and efficacy, particularly when a multi-level procedure is involved. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested air ambulance service for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the air ambulance service was not medically necessary for treatment of the patients medical condition. In general, air transport is considered medically necessary when there is significant risk of decompensation with other forms of transportation, or when accessibility is an issue. In this case, the patient was having near syncopal episodes for a few days prior to seeking medical attention. While hospitalized at the treating facility, the patient was stable and had no further near syncopal episodes. In addition, a comprehensive work-up was negative. As such, the requested air ambulance service has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 pediatrics and pediatric critical care 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 3-year-old male enrollee has requested speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is a medically necessary intervention for this patient with autism given his history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions for autism in peer-review research articles and found sufficient evidence supporting the effectiveness of interventions to teach communication skills to children with autism. Specifically, language skills make a significant difference in the ability of children to control their environment, especially with disruptive behaviors. As language deficits are one of the core aspects of autism for which speech therapy provides professional guidance on communication development, the requested two hours per week of speech therapy (past and future) has been shown to be medically necessary for treatment of this patients autism related delays. Concerning the requested occupational therapy, this modality is considered a standard treatment intervention for patients with autism. The submitted records indicate the patient has previously had documented delays in fine motor and gross motor abilities. Therefore, I find that the patients previous occupational therapy was medically indicated and necessary. With regard to the request for future occupational therapy service, the patients most recent occupational therapy on the date in question (by an in-plan provider) indicated the patient presented with no apparent occupational therapy problems. However, the patient was noted not to scribble spontaneously (this is typically developmentally noted at 18 months of age). Of further significance, this evaluation did not include a reliable testing measure to determine the extent of the patients fine motor and gross motor abilities. The Vineland Adaptive Behavior Scales-second edition (VABS) and Mullen Early Scales of Learning on the said date found deficits of up to 33% on fine motor abilities. Given the inconsistent results on previous evaluations, the patient should have an objective independent evaluation to determine his occupational therapy needs going forward.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested Lyrica for treatment of her transverse myelitis of the cervicothoracic cord from C4-T4 in the setting of Lupus.  Findings:  The physician reviewer found that the literature including Tuchman, et al., and Moore et al., clearly show the efficacy of Lyrica from sound biochemical basic pathways and inhibition of calcium channels in peripherally, (i.e. diabetes, or post-herpetic neuralgia) and centrally mediated (i.e. post-stroke, transverse myelitis, or multiple sclerosis) syndromes. The cortical perception of pain in the primary somatosensory cortex and thalamus transmit neuropathically mediated pain signals the same no matter the pathophysiological cause. Therefore, the neuropathic pain guidelines support Lyrica as a first-line agent for this condition. Given that this patient experienced superior pain relief from a moderate dose of Lyrica (300 mg per day), when compared with a high dose of Neurontin (2700 mg per day), it is clinically appropriate for Lyrica to be approved as medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested Botox injections for treatment of her intractable migraine.  Findings:  Three physician reviewers found that Botox injections are not likely to be more beneficial for the treatment of the patients chronic daily headaches than any available standard therapy because the effectiveness of Botox not been proven or confirmed within the peer-reviewed literature for treatment of her condition. In the clinical trials, Matthew and colleagues performed a randomized double-blinded, placebo controlled trial on Botox for the prophylactic treatment of chronic daily headaches. The trial resulted in patients having on average, approximately, seven more headache free days compared to baseline. The treatment also met secondary efficacy outcome measures, including the percentage of patients experiencing a 50% or more decrease in the frequency of headache days per month. Thus, Botox treatment for chronic daily headaches seems promising and is well tolerated. However, the efficacy of Botox treatment for headaches is not proven to be statistically significant in trials or in the peer reviewed literature. Further, Silberstein and colleagues studied the safety and efficacy of different concentration of Botox for prophylactic use in chronic tension type headaches. The researchers concluded that there was no statistically significant difference between placebo and the four groups treated with Botox. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The authors concluded that there were no statistically significant between-group differences in the frequency of migraine episodes per 30-day period. As such, Botox injections for episodic, chronic, tension-type headaches or migraines may provide substantial, sustained improvements in symptoms. However, a statistically significant difference between treatment groups and placebo could not be obtained to prove that Botox for headaches is more beneficial than any available standard therapy. With respect to this patient, there was no documentation by the treating physician that the patients headache frequency was substantially reduced by the end of the initial trial. Therefore, the Health Plan has appropriately denied the patients request for authorization for Botox as the records fail to suggest that it is likely to be more beneficial for treatment of her condition than conventional modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mandibular orthopedic repositioning device and associated services, including consultation and appliance molding for treatment of the enrollees articular cartilage disorder. Findings:  The physician reviewer found that the current medical evidence supports the device at issue and services at issue in this clinical setting.  The performance of a patients history and clinical examination is well-accepted to identify the presence or absence of temporomandibular joint disorder.  Additionally, there are many other tests and diagnostic studies that are employed in the treatment of temporomandibular joint disorder, such as surface/needle electromyography, thermography, sonography, electrovibrography, and mandibular kinesiology (jaw tracking). Splint therapy has been shown to be beneficial in patients with temporomandibular joint disorder and myofascial pain.  This modality has been shown to decrease symptoms.  All told, mandibular orthopedic repositioning device and associated services, including consultation and appliance molding were medically indicated for the treatment of this patient. Final Result: The reviewer determined that the device at issue and services at issue were 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 oral and maxillofacial 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: Upheld

An enrollee has requested authorization and coverage for Stelara Prefilled Syringe. The submitted documentation does not support that the requested medication is medically necessary. Peer reviewed medical literature supports that Stelara (ustekinumab) is a recommended treatment of both psoriatic arthritis and psoriasis. In this case, however, the patient has recently started Enbrel (etanercept), a tumor necrosis factor (TNF) blocker, and the submitted documentation has no indication of failure of Enbrel or of a provider rationale for an additional medication (Stelara) at this time. Under these circumstances, the requested Stelara Prefilled Syringe is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, 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 fifty-nine year-old female who has been diagnosed with shingles, lateral epicondylitis and complex regional pain syndrome is requesting authorization of Lyrica.Reviewers Findings:  The reviewing physician found that Lyrica has not been well studied or proven effective for treatment of the patients diagnosed conditions.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ensure Complete Liquid. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested supplement. The records do not document malabsorption, metabolic syndrome or enteral nutrition given via a feeding tube. The documentation does not support that the patient experienced significant recent weight loss. The treatment of weight loss should be aimed at the underlying illness or medical condition, as well as dietary modification. Nutritional supplements are recommended when patients experience weight loss and dietary modification has not been effective to help them gain weight. This patient has a diagnosis of chronic fatigue syndrome. Various therapies have been tried in patients with chronic fatigue syndrome. Management is supportive and focused on treating common symptoms and comorbid conditions, which include sleep disorders, pain, depression and anxiety, memory and concentration difficulties, dizziness and lightheadedness. In this case, the records do not document a medical condition that would prevent the patient from consuming a regular diet. The records do not support that the patient has dysphagia or dental problems. Therefore, the requested Ensure Complete Liquid is not medically necessary for this patient.Final Result: The reviewer determined that the requested supplement 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 internal 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested sclerotherapy for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support sclerotherapy in this clinical setting.  This patients records indicate that she has spider veins, and there are only specific situations where sclerotherapy for spider veins is medically indicated.  The submitted documentation does not demonstrate how treating these veins would help with her symptoms.  All told, sclerotherapy is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.A 55-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his adenocarcinoma of the gastroesophageal junction.Two physician reviewers found that intensity modulated radiation therapy is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. Intensity modulated radiation therapy generally implies inverse planning algorithms. Specifically, the physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or temporally. Distal esophageal cancers, particularly gastroesophageal junction adenocarcinomas, behave similarly to and are treated similarly to gastric cancer, and these disease entities are often combined in large studies. In the studies by Milano and colleagues and Ringash and colleagues, intensity modulated radiation therapy reduced the dose to the liver and kidneys, as well as the heart and spinal cord. In a study of patients with distal esophageal cancer by Chandra and colleagues, intensity modulated radiation therapy was shown to reduce the dose-volume of normal lung. The submitted documentation does not justify the use of intensity modulated radiation therapy in this patients case. Arguably, the data supporting the use of intensity modulated radiation therapy for these indications are scant. The medical records submitted do not document the need to spare critical structures with intensity modulated radiation therapy. The radiation dose can potentially be escalated using 3D conformal radiation techniques, particularly if the final prescribed dose is to be on the order of 50-54 Gy (which is the standard dose used for preoperative chemoradiation as well as definitive chemoradiation). Thus, there is a lack of support demonstrating that intensity modulated radiation therapy would be better than standard 3D conformal radiation in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested for Daklinza 60 mg, Sovaldi 400 mg and ribavirin 200 mg for treatment of the enrollees hepatitis C virus. The Health Plan indicates that the preferred regiment for genotype 3 treatment naive patients with compensated cirrhosis is Epclusa for 12 weeks.  Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, treatment-naive genotype 3 patients should be treated with Sovaldi and Daklinza for 12 weeks, or Epclusa for 12 weeks. This is based on the ALLY-3 trial for Sovaldi and Daklinza, and the ASTRAL-3 trial for Epclusa (Nelson, et al; Foster, et al). Per the guidelines, treatment with Sovaldi and Daklinza with ribavirin regimen is not recommended. Furthermore, there is no medical contraindication to Epclusa noted in the records provided for review. Although hepatitis C treatment is indicated, Sovaldi 400 mg and Daklinza 60 mg with ribavirin 200 mg has not been established as medically necessary for the treatment of this patients hepatitis C virus.Final Result: The reviewer determined that the requested medications 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 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: Urgent Care
Decision: Upheld

A 51-year-old female enrollee has requested emergency ambulance transportation as a result of her medical condition. Findings:  The physician reviewer found that California law defines an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his or her health to be in jeopardy without immediate medical attention. The issue in this case is whether a prudent layperson would have sought ambulance transportation for nausea, vomiting, headache and abdominal pain. The submitted evidence does not demonstrate the patients health was in jeopardy if she was not treated immediately. The patients vital signs were normal and she did not receive any treatment while in the ambulance. In the ER, the patient received antiemetics and some intravenous fluids. She was discharged in stable condition three hours after her arrival to the ER. The patient was in stable condition throughout her stay in the ER. The evidence does not support the contention that the patients symptoms were so severe as to cause a prudent layperson to seek ambulance transportation.