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

Nature of Statutory Criteria/Case Summary: An enrollee's parent has requested authorization and coverage for a high frequency chest wall oscillation system for treatment of the enrollees Cockayne syndrome and microcephaly. Findings:  The physician reviewer found that Cockayne syndrome is a rare form of dwarfism associated with microcephaly, prognathism, abnormal dentition, kyphosis, hypohidrosis, cataracts, hypertension, hepatomegaly, and others. High frequency chest wall oscillation was developed to improve airway clearance in patients where the normal mucociliary transport system has failed. Research supports the utility of these systems in airway clearance in this clinical setting. Vest therapy has been studied in children with cystic fibrosis and quadriplegic cerebral palsy. In patients with familial dysautonomia, high frequency chest wall oscillation effected significant improvements in all health outcomes and oxygen saturation. In one study of children with either cerebral palsy or neuromuscular diseases, the authors concluded that, our data suggest safety, tolerability, and better compliance with high-frequency chest wall oscillation. Improvement in airway clearance may help prevent hospitalizations. This patient has severe developmental delay, poor airway clearance, and is an aspiration risk. She is not able to participate in most methods of airway clearance effectively as a result. She has used high frequency chest wall oscillation during her many hospitalizations for airway issues, and has tolerated it with good results. The literature supports use of this airway clearance technique in patients with deficiencies in airway clearance. Given these findings, the requested high frequency chest wall oscillation system is supported as medically necessary for treatment of this 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 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 patient is a 49-year-old female with history of spasmodic dysphonia for approximately 10 years and dystonia since March 2004. Per review of the submitted medical records, the patients spasmodic dysphonia has improved with speech therapy. The patients provider has requested authorization for acupuncture for treatment of the patients dystonia. The Health Plan has denied this request indicating acupuncture is not medically necessary for treatment of the patients condition.Review of the submitted clinical information indicates the patient has a history of spasmodic dysphonia for approximately 10 years with favorable response to speech therapy. With regard to the patients dystonia, she has failed physical therapy. She has attempted yoga and attends support groups, but continues to experience symptoms. Review of the submitted medical literature reveals that in addition to conventional methods for treatment of dystonia, there are complementary or alternative methods including acupuncture, homeopathy, massage, and biofeedback therapy. Since there is evidence in support of acupuncture for treatment of dystonia, a trial of the requested therapy would be medically reasonable and appropriate in this case. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should undergo a trial period of acupuncture at a frequency of twice a week for four weeks with re-evaluation at the end of the trial period. If there is documented evidence acupuncture has been beneficial for the patients condition, additional acupuncture should be authorized. If there is not documented evidence acupuncture has been beneficial for the patients condition, additional acupuncture should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested hydrocodone-ibuprofen 7.5-200mg, 250 tablets per month for treatment of her fibromyalgia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The current standard of care for chronic pain associated with fibromyalgia is treatment in a multidisciplinary practice to include physical therapy, behavioral therapy, and possibly injections to help reduce pain.  However, the medical literature does not support the requested medication in this clinical setting.  As noted by Baron and colleagues, high-dose and short-acting opiates may contribute to pain sensitization via opioid-induced hyperalgesia.  Ballantyne and Mao noted that prolonged use of high-dose and short-acting opiates may induce abnormal pain sensitivity.  All told, hydrocodone-ibuprofen 7.5-200mg, 250 tablets per month are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old female who has a history of symptomatic reticular varicose veins and telangiectasia. She also has a family history of varicose veins. The patients provider recommended sclerotherapy injections, which she underwent on 7/15/04 and 8/26/04. She has requested reimbursement for the injections at issue. The Health Plan has denied the patients request stating the injections at issue were not medically necessary for treatment of the patients medical condition.The patient has telangiectasia and reticular veins. These findings are not sufficient to justify sclerotherapy. Sclerotherapy of telangiectasias and reticular veins is usually performed for cosmetic reasons and repeat injections are required over the years. The documented evidence does not demonstrate sclerotherapy is medically warranted.  Therefore, I have determined that the injections at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested a series of Orthovisc injections for treatment of his bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the usefulness of viscosupplementation in the treatment of mild to moderate osteoarthritis in the knee has been generally accepted in medical practice (Dagenais). In addition, the value of viscosupplementation in other joints has been reported as showing promising results. However, the efficacy of repeated injections remains under investigation (Strauss, et al). Clinical trials of viscosupplementation following meniscal surgery or in arthritic joints are currently being studied to evaluate its role, if any, in pain control. Currently, there is a paucity of reliable scientific data in the literature establishing the value of viscosupplementation for the treatment of meniscal injury. As such, the requested Orthovisc injections have not been proven to be medically necessary in the treatment of this patients knee condition.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee has requested OxyContin and Xanax for treatment of her chronic pain and anxiety. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The current medical evidence does not support the requested medications in this clinical setting.  The records note a positive urine drug screen for cocaine. There is a lack of documentation with improved function on the opioid and benzodiazepine medications.  Current standard of care for chronic non-malignant pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald 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.  Combination opioids and benzodiazepine are synergistic and may cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  All told, the requested OxyContin and Xanax are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 22-year-old female with myotonic muscular dystrophy and frequent respiratory infections. She has recurrent pneumonia secondary to her muscular dystrophy. According to her pulmonologist, the patient was hospitalized for 14 days in 2005 for pneumonia. She had been tried on various secretion clearance methods including chest physiotherapy, Flutter device and postural drainage. The pulmonologist ordered the Vest System for the patient in September 2005. Her condition improved and she was able to return to her baseline health status. The patients father indicates he has observed improvement in the patients health since she began using the Vest System and she has been able to return to her disabled adult work experience program.The Health Plan denied authorization and coverage for the Vest System concluding that there was not sufficient evidence to support the use of the Vest System in patients with muscular dystrophy. The purpose of this review is to determine if the Vest System is medically necessary for treatment of the patients medical condition.The material provided for review included articles supporting the use of external high-frequency oscillation (HFO) in patients with various neuromuscular diseases. Giaraffa et al. found improvement in all health outcomes, peak flows and FVC in patients using HFO. Piloplys et al. found less pneumonia and fewer hospitalizations in cerebral palsy patients using the Vest System.Secretion clearance is extremely important in preventing respiratory infections. Factors which influence clearance are mucus viscosity, an intact mucociliary system and an effective cough. The patient has a severe neuromuscular illness, which results in an ineffective cough. She had been on various secretion clearance methods including the Flutter device, postural drainage and an IPV machine. Since all the previous methods were ineffective, it was appropriate for the patient to undergo a trial of the Vest System. The patient has had significant improvement and improved quality of life since using the Vest System. As such, the patients continued use of the Vest System is medically reasonable and appropriate and indicated for secretion clearance.Based upon the information set forth above, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested IVIG therapy for treatment of her history of herpes simplex keratitis. Findings:  Three physician reviewers found that the submitted medical records fail to demonstrate that IVIG therapy is likely to be more efficacious than other treatment options.  There is no laboratory support for a diagnosis of herpes infection, and there is no evidence of IgG deficiency.  Based upon the submitted documentation, the patients total IgG levels have been normal.  Per the current medical literature, there is insufficient support for the requested therapy for ocular herpetic infection.  Therefore, the requested IVIG therapy is not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 67-year-old male enrollee has requested Harvoni 90mg/400mg for 12 weeks for treatment of his hepatitis C. Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting.  Per the current medical evidence, successful hepatitis C treatment results in sustained virologic response.  Based upon this patients Metavir score, treatment is indicated.  There is support for Harvoni for patients with hepatitis C, genotype 1 infection who do not have cirrhosis and who have failed prior interferon and ribavirin treatment.  Thus, the requested Harvoni 90mg/400mg for 12 weeks is medically indicated in this patients case.
Appeal type: Urgent Care
Decision: Overturned

A 56-year-old female enrollee has requested for emergency services at issue were not required on an emergent basis. Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson in the enrollees circumstances would have sought immediate medical attention. 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.A prudent layperson would reasonably seek immediate medical attention for acute-on-chronic polysubstance use relapse in the context of a post-operative state and peri-surgical infection combined with multiple medical problems, including hypertension and hypothyroidism. The American Psychiatric Association (APA) Clinical Practice Guidelines states ambulatory detoxification with co-occurring general medical conditions may be unsafe.  Therefore, seeking immediate medical attention was reasonable in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high intensity focused ultrasound (HIFU) services. HIFU consists of focused ultrasound waves that cause tissue damage by mechanical and thermal effects as well as by cavitation. Potential candidates for HIFU treatment are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short- to intermediate-term outcomes for localized prostate cancer. Overall, there is a lack of controlled trials for analysis or research on long-term patient health outcomes. The National comprehensive Cancer Network (NCCN) guideline noted that HIFU warrants further investigation as an emerging local therapy, but noted that data are lacking to establish its role in the treatment of prostate cancer. The National Cancer Institute does not list HIFU as one of the seven standard treatments for patients with prostate cancer. Moreover, the American Society for Radiation Oncology (ASTRO) guideline states that HIFU is not considered a standard care option because comparative outcome evidence is lacking. As such, HIFU is not a clinically appropriate and generally accepted standard of care for management of localized prostate cancer. This patient was initially diagnosed with a Gleason score of 6 with a prostate specific antigen (PSA) of 4.4. The current guidelines and medical literature do not support the long-term safety and efficacy of HIFU in this clinical setting. Given these findings, the HIFU surgery services were 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 HIFU surgery services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil 200 mg, twice daily for treatment of the enrollees hypersomnia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The documentation noted idiopathic hypersomnia. The multiple sleep latency test revealed a mean sleep latency of eight minutes with no rapid eye movement sleep.  This is diagnostic of this condition.  Idiopathic hypersomnia is a clinical variant of narcolepsy and is treated the same way.  In both disorders, the mean sleep latency test reveals a mean sleep latency of less than 10 minutes.  In narcolepsy, there is rapid eye movement sleep documented.  In idiopathic hypersomnia, the sleep latency is identical, but there is no rapid eye movement sleep documented.  The requested medication is the generally accepted treatment for this patients condition.  All told, modafinil 200 mg, twice daily is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 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 27-year-old female enrollee, who has a small abdominal pannus and is said to have pruritus and moisture in the pannus fold, has requested authorization for a panniculectomy.  Findings:  The physician reviewer found that physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. Surgical intervention should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400-100 mg for 12 weeks for treatment of her chronic hepatitis C virus genotype 2b. 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. In addition, a delay in treatment may result in decreased survival. Final Result: The reviewer determined that the requested medication 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 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: Overturned

A 63-year-old female enrollee has requested for participation in the requested phase 1-2 clinical trial for Hana Biosciences Marqibo for treatment of her choroidal melanoma with liver and lung metastases.  Findings:  Two physician reviewers found that the rare form of melanoma found in this case is a very uncommon, highly aggressive malignancy for which no standard therapy exists. This patient has been offered the opportunity to participate is a clinical trial specifically for patients with uveal melanoma. As addressed by Houghton and colleagues, in their discussion of the National Comprehensive Cancer Network (NCCN) practice guidelines for melanoma, participation in a clinical trial would be the highest recommendation for this patient and most likely to prolong her survival.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a transgender male to female with a diagnosis of gender dysphoria and reports continued symptoms despite conservative treatments. She shared that she experiences emotional distress and anxiety daily. FFS would provide reconstructive surgical services for an abnormality as a result of the patients disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. The guidelines for the medical necessity of FFS exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. The WPATH states that in addition to hormonal balancing, facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. This patient has a documented history of gender dysphoria and has been treated with cross-gender hormone therapy. The patient is noted to have emotional distress daily due to the presence of masculine physical facial features. Based on the documented history of gender dysphoria and evidence in support of the medical necessity of FFS, all of the requested surgeries are found to be medically necessary for treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.