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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Subsys (fentanyl sublingual spray) for treatment of his medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Subsys (fentanyl sublingual spray) has not been established. According to the documentation submitted for review the patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The medical literature reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High dose and short acting opiates may also cause adverse outcomes and, therefore, the patients request for coverage for Subsys is not indicated. The medical literature reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons provided, the patients request for Subsys is not medically necessary.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an implantable ambulatory event monitor. Findings:  The physician reviewer found that Forleo and colleagues report that continuous rhythm monitoring over long periods of time is superior to intermittent recording using external monitors to detect the presence of atrial fibrillation episodes and to quantify the atrial fibrillation burden. The authors further note that implantable devices for continuous atrial fibrillation keep detailed information about arrhythmia recurrences. In this case, the patient has undergone two radiofrequency ablation procedures and continues to experience palpitations that may be related to recurrent atrial fibrillation. A two-week event monitor did not reveal recurrent atrial defibrillation. The patient has easy bruising on Xarelto. In this case, given that an assessment of the safety of discontinuing Xarelto would depend on the patients atrial fibrillation burden based on long-term monitoring, the requested device is medically indicated. Therefore, an implantable ambulatory event monitor is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested device is medically necessary for evaluation 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 cardiovascular disease 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 47-year-old female enrollee has requested bilateral excision of breast tissue for the treatment of her bilateral lipomas. Findings:  The physician reviewer found that excision of the axillary breast tissue is medically necessary. Accessory breast tissue can be painful during the menstrual cycle and may present problems with breast cancer screening, both of which have been problems for this patient.  The tissue serves no functional purpose, and the medical records describe axillary pain for over one year. Breast cancer can arise in axillary breast tissue and carries a poor prognosis because of the often delayed diagnosis. The patients axillary breast tissue is causing functional problems with activities of daily living.  Her complaints are similar to those described in the medical literature for women with axillary breast tissue, and surgery is curative.
Appeal type: Experimental/Investigational
Decision: Overturned

A 26-year-old male enrollee has requested Botox injections for the treatment of his chronic headaches. Findings:  Three physician reviewers found that Botox has been used for both episodic and chronic migraine with mixed results. The literature suggests a modest positive effect in refractory patients who have more than 15 headaches per month. There is also some literature that suggests that Botox enhances the response to narcotic medication withdrawal in patients with medication overuse headache. Most headache specialists now recommend Botox therapy for refractory chronic migraine patients. Given the patients refractory chronic daily headache and failure to respond to nearly all previously tried standard therapy, Botox injections are more likely to be efficacious than standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee requested the LINX Reflux Management System procedure and esophagogastroduodenoscopy (EGD) for medical treatment of her gastroesophageal reflux disease (GERD).  Findings:  Three physician reviewers found that there is a lack of controlled trials comparing the efficacy and safety of LINX to Nissen fundoplication. Moreover, Nissen fundoplication has been found superior with symptomatic improvement occurring in 85 to 90 percent of patients. Finally, the request for a repeat EGD is not clinically indicated as the patient has already had three EGD exams and a repeat EGD is not likely to be more beneficial for treatment of the patients medical condition than other modalities. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment services for treatment of the enrollees substance abuse. Findings:  The physician reviewer found that the patient was not in withdrawals as she had only used once and did not require detoxification. She was not a danger to herself or others and she was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential treatment center (RTC) level of care. She was not psychotic or manic and she was medically and psychiatrically stable. Her medication regimen could have been managed in an ambulatory setting. She was cooperative and participated in her treatment plan. She had multiple prior treatments and therefore had a base of knowledge from which to continue to build her relapse prevention plan. Her difficulties with abuse and relapse were chronic in nature and did not require 24-hour monitoring in the absence of unstable medical or psychiatric conditions. She could have safely been treated in an ambulatory level of care, with the assistance of medically assisted treatment such as suboxone for opiate use disorder if deemed appropriate by her provider. Final Result: The reviewer determined that the services at issue were 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 sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg for treatment of the enrollees hepatitis C. The Health Plan indicated that the requested medication is not medically necessary.  The Health Plan noted that coverage for Zepatier would be provided as an alternative. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  These guideline recommendations are based on multiple randomized clinical trials.  The guidelines also support Zepatier for 12 weeks in this clinical setting.  In genotype 1a patients with negative testing for NS5A resistance-associated variants, Zepatier for 12 weeks is medically appropriate.  The records do not demonstrate a contraindication to Zepatier in this patients case.  Therefore, Harvoni 90-400 mg is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency ablation. Findings:  Three physician reviewers found that the currently accepted practice guidelines support the use of radiofrequency ablation in Barretts esophagus when high-grade dysplasia is present, and in particular cases in which low-grade dysplasia is present. There are no formal recommendations supported by high-quality evidence to perform ablation in patients with non-dysplastic Barretts esophagus. American College of Gastroenterology recommendations do not recommend ablation of non-dysplastic Barretts esophagus. As there is no evidence of dysplasia of Barretts esophagus in this case, the superior effectiveness of radiofrequency ablation has not been demonstrated. Final Result: The reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in gastroenterology 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

The representative of a 65-year-old male enrollee has requested continued rehabilitation services (physical and occupational therapy) at a skilled nursing facility for the treatment of the enrollee, who is status post CVA. Findings:  The physician reviewer found that the rationale for the denial appears to be related to social resources. The patient was denied continued rehabilitation because he would remain in a skilled nursing facility and require 24 hour supervision. The rationale is independent of the clinical progress he was making, albeit slowly. On 5/29/08, the patient required moderate assistance with bed mobility and moderate/minimal assistance with transfers. Two weeks prior, he was moderate/maximum to maximum assist in these modalities. He showed similar progress with occupational therapy. His progress precludes predicting what his precise functional gain will be. There are no clinical algorithms or other predictive tables that permit such a prediction. He is unlikely to gain neurologic recovery, and his progress with rehabilitation is slow, but the standard for stopping rehabilitation is that the patient has reached a functional plateau and is not expected to benefit from additional intensive rehabilitation, as opposed to range of motion or exercise.
Appeal type: Urgent Care
Decision: Overturned

A 33-year-old female enrollee has requested an emergency room visit for the treatment of her fever, cough and myalgias. Findings:  The physician reviewer found that the symptoms and signs that this patient presented with are consistent with a potentially serious disease. Many life-threatening and potentially lethal infections begin with vague and nonspecific symptoms, including myalgias and fever. Without timely medical evaluation and treatment, these infections can lead to rapid deterioration. Although the patient had been sick for four days, her symptoms worsened. Being concerned regarding her medical condition, the patients only source of urgent medical evaluation was at an urgent care or emergency facility.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Oncotype DX gene expression test for evaluation of his medical condition.   Findings:  Two physician reviewers found that Oncotype DX assay is an assay of specific genes in an individuals cancer cells. It has become widely accepted as useful in the treatment decision with early breast cancer.  A similar assay has been developed for prostate cancer, in the hopes that the assay would allow the provider to determine if an individual had a prostate cancer that needed specific treatment, versus watchful waiting only. The technology has been validated as reliable.  However, it has not as yet been shown to enable a clinician to make a decision about treatment that is superior to that decision made by more conventional criteria, such as the age of the patient, Gleason grade, extent of the cancer, and prostate specific antigen.  He does not fulfill the criteria used to define low-risk, thus, he would be classified as intermediate risk.  There is a lack of reliable data demonstrating that making a treatment decision incorporating Oncotype DX gene expression testing is an improvement over a clinical criteria decision alone.  Therefore, Oncotype DX gene expression testing was not likely to have been of greater benefit than other modalities. Final Result: Two 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for sclerotherapy for the enrollees varicose veins. Findings:  Three physician reviewers found that this patient is diagnosed with bilateral varicose veins that were associated with aching, heaviness and edema in both lower extremities.  The records do not document a history of complications with varicose veins.  Varicose veins and reticular veins were identified.  There were no venous duplex to evaluate reflux, so it is not known if this patient has axial reflux or previous deep vein thrombosis symptoms in either leg. The treating provider performed both sclerotherapy and cutaneous laser therapy. The patient requested reimbursement for the sclerotherapy treatments performed. The patient is also requesting prospective authorization and coverage for future sclerotherapy treatments. The Health Plan has denied the services at issue as investigational for treatment of this patients medical condition. This denial is the subject of this appeal and determination. The medical literature suggests that both direct and ultrasound guided primary venous sclerotherapy are limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. In this patients case, the submitted documentation fails to demonstrate that this patient had appropriate work-up prior to the sclerotherapy treatments performed. Therefore, these interventions were experimental as to the treatment of this patient. Moreover, without documentation of appropriate work-up, future sclerotherapy would also be investigational.  As such, the sclerotherapy treatments performed on were not and are not likely to be more effective than other methods of therapy for this patient. Final Result: The reviewers have determined that the services at issue were not and are 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: All three physician reviewers are board certified in vascular 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: Experimental/Investigational
Decision: Overturned

A 27-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS).  Findings:  Two physician reviewers found that the patient has a history of major depressive disorder, recurrent, severe. She has requested coverage for transcranial magnetic stimulation (TMS) treatment from a specific date and forward. She presents with depressed mood, psychomotor slowing, tearfulness, hopelessness and suicidal ideation. She has impaired functioning socially and occupationally. Her condition has been severe enough recently to require hospitalization. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Celexa, Prozac, Effexor, Cymbalta, Pristiq, Effexor, Wellbutrin, Remeron, Nortriptyline, Lamictal and Lithium which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches have also yielded inadequate therapeutic effect. The patient requests coverage for TMS treatment for her depression provided from the date in question and forward.  Schutter and colleagues reported that TMS had a moderate effect of TMS on treatment resistant depression. George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that TMS is a safe and effective treatment for major depressive disorder. In addition, the American Psychiatric Association (APA) practice guidelines for treatment of depression state that the (A)cute phase treatment may include TMS. Connolly and colleagues also noted that, TMS was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression. Thus, although relatively new, TMS is an effective treatment and is FDA approved for the treatment of treatment resistant major depressive disorder. Based on these findings, the TMS therapy at issue was and is likely be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar revision. The submitted documentation does not support that the requested services are medically necessary. The literature supports that in the case of hypertrophic scarring, the timing of surgical treatment is an important consideration in the treatment protocol of scar revision strategy. Hypertrophic scars may mature over at least a one-year period and can show significant flattening and softening without any physical manipulation. In this case, the patient has scar hypertrophy in the lateral breast scars six months after reduction mammoplasty. There is no indication for early excision of hypertrophic scars to prevent further hypertrophy. There has been an insufficient amount of time for scar softening to occur. Under these circumstances, the requested scar revision is not medically necessary for treatment of the patients medical condition at this time.Furthermore, the submitted documentation does not support that the requested services constitute reconstructive surgery. Under California law, reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or create a normal appearance, to the extent possible. If the surgery is intended to create a normal appearance, it must offer more than a minimal improvement in appearance. California law mandates that health plans must cover reconstructive surgery. In this case, scarring after breast reduction surgery is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. The patient has scar hypertrophy in the lateral breast scars six months after reduction mammoplasty. Scarring after breast reduction surgery does not constitute a significant abnormal structure of the body. Hypertrophic scars may mature over at least a one-year period and can show significant flattening and softening without any physical manipulation. The records state the patient has difficulty sleeping on her left side due to discomfort but do not support deficits in function. Accordingly, the requested scar revision is not reconstructive in nature.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 plastic 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.