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

The parent of an 11-year-old male enrollee has requested consultation and treatment with a dermatologist for the treatment of the enrollees warts. Findings:  The physician reviewer found that the patient is requesting a referral to a dermatologist for evaluation and treatment of verruca vulgaris on the bilateral hands that has been unresponsive to over-the-counter freezing sprays (two applications).  The patients primary care physician does not have liquid nitrogen therapy available, and the physician has recommended that the patient be evaluated and treated by a dermatologist given the recalcitrant nature of the lesions, number of lesions and location of lesions.  Expectant, watchful waiting has not resulted in a resolution of the lesions over a six-month period. Waiting an additional two to three months without treatment is likely to result in spreading of the remaining lesions. Other treatment modalities exist for warts, including topical Canthacur, intralesional candida antigen, intralesional bleomycin and topical squaric acid dibutylester contact sensitizers.  Referral to a dermatologist is medically indicated for this patient so that treatment options can be discussed and treatment can be obtained without delay.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Game Ready recovery technology device for treatment of the enrollees articular cartilage disorder. Findings:  Three physician reviewers found that the current peer-reviewed medical literature does not include any randomized controlled trials studying the effects of combined cyclic compression and cryotherapy in major hip surgery. This patient underwent left hip arthroscopic labral repair, acetabular rim resection, and femoral CAM resection and was prescribed a Game Ready device for home use. She reported prior benefit with the use of the Game Ready device during post-operative physical therapy following prior left hip surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this patients condition.  Final Result: The reviewers determined that the requested device 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. Credentials/Qualifications: 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: Overturned

A 21-year-old female enrollee has requested left foot hallux valgus/bunion surgery for treatment of her hallux valgus.  Findings:  The physician reviewer found that after careful review of the submitted information it is my opinion that the requested left bunionectomy is medically necessary for the treatment of the patients painful medical condition. The patients left foot pain has apparently been present for quite some time and has not responded to conservative care including padding and inserts. The patient indicates that her left foot pain is inhibiting her ambulation. In addition, the patients bunion deformity has been clinically diagnosed by x-ray. As noted in numerous medical studies, bunionectomies are very successful surgical procedures performed to correct a malpositioned toe or bunion deformity. For these reasons, the requested surgery meets the criteria for medical necessity since it is required to treat a malformed body part which is causing the patient pain. Furthermore, a bunionectomy is in accordance with generally accepted standards of medical practice, and not being performed for the convenience or cosmetic purposes. Accordingly, the requested surgery has been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee requested authorization and coverage of Synvisc injections for treatment of early arthritis in both knees. The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested injections are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Subutex 2 mg sublingual (SL) twice daily for treatment of the enrollee who has a history of low back pain. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication. Behavior therapy was not noted as performed despite much research to support its use. Additionally, not all non-opioid medications classes have been optimized or tried.  Also, there are other non pure mu agonist that have long lasting duration that may be available to the patient. There is no documentation of counseling despite research and recommendations to support its use in opioid dependency. It is unclear what the plan is for this patients opioid dependency since the notes state she is taking Tramadol and buprenorphine (Subutex). Moreover, there is no clear objective functional goals for the buprenorphine being requested. Buprenorphine is U.S. Food and Drug administration approved and indicated for opioid dependence. However, the patient states she is taking the medication for pain control. Furthermore, it is unclear from the records why the provider and the patient believe Suboxone should be avoided; Suboxone is sufficient. In addition, while the provider states that there is a desire to be off all opioids, the medical record does not show that this patient has been weaned off Norco and fentanyl, given the request for 99 refills on the buprenorphine sublingual. Finally, despite drug testing being noted in the plan, there are no laboratory data submitted as to the results of those tests. Moreover, multiple minimal requirements for opioid prescribing have not been performed. The need to use buprenorphine alone or alongside another opioid, for an indefinite basis, as the primary medication treatment strategy for pain or opioid dependency has not been established. For all these reasons, the requested coverage for Subutex 2 mg SL, twice daily, is not medically necessary for treatment of this 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-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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested medical services on an emergent or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients 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. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. The submitted documentation demonstrates the patient reasonably believed she was experiencing an emergency medical condition. In this case, the patient had been evaluated recently for chest pain. A subsequent CT scan reading noted an aortic aneurysm. In this case, the patients chest pain may have been caused by the dissection of such aneurysm. The patient was specifically instructed to call or return to the emergency department. Despite the lack of symptoms during the patients repeat visit, the fact remains that when she was instructed to return to the emergency department, it was reasonable for her to believe that the absence of immediate medical attention could result in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. In sum, a prudent layperson in the patients circumstances would have sought immediate medical attention.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee has requested BRCA 2 Genetic Testing for evaluation of his medical condition.   Findings:  The physician reviewer found that though there are extensive guidelines for BRCA testing in women, the guidelines for testing men without a personal history of cancer are not as clearly defined. Some guidelines do include testing of men who have a first or second-degree relative who is known to be BRCA positive. The National Comprehensive Cancer Network (NCCN) guidelines also recommend testing for anyone with a first or second-degree relative who is known to be BRCA positive.  While the clinical utility of BRCA testing in males is still being studied, there is evidence that men with BRCA 2 deleterious mutation are at increased risk for the eventual development of breast cancer and possibly prostate and pancreatic cancer. This information may also be useful for the offspring of an affected male.  As there are medical records provided that indicate the patient has both first and second degree, as well as male and female, relatives with positive BRCA 2 deleterious mutations, the BRCA 2 testing is reasonable and would qualify as medically necessary
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee, with diabetes mellitus type II (DM2), has requested coverage for Byetta. Findings:  The physician reviewer found that there are alternative treatments that do not appear to have been tried, such as meglitindes, low dose thiazolidinediones or low dose basal insulin. Although the patients hemoglobin A1c decreased with the use of Byetta, there is as yet no data on the benefit of lowering a hemoglobin A1c from 6.1% to 5.6%.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy, 19.5 hours per month of supervision and four hours per month of parent training for treatment of the enrollees autism. Findings: The physician reviewer found that ABA therapy is medically necessary for the treatment of children with autism spectrum disorder. Orinstein and colleagues found that children who started ABA therapy at an earlier age and at a higher level were more likely to have an optimal outcome. Sallow Graupner support a high level of ABA services in the first and second year of ABA therapy. In this case, the patient is in his second year of ABA therapy and requires a high level of ABA therapy due to the patients maladaptive behaviors including aggression, non-compliance and screaming behavior. There is sufficient support for the medical necessity of 172 hours per month of direct ABA therapy, 19.5 hours per month of supervision and four hours per month of parent training in this clinical setting.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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 53-year-old female enrollee has requested sclerotherapy for treatment of her spider telangiectasis.  Findings:  The physician reviewer found that based on the records provided for review, the requested procedure is not reconstructive in nature and not medically necessary for this patient. The patients condition does not constitute an abnormal structure of the body. In addition, the documentation does not support that the proposed procedure is directed at relieving the patients severe symptoms. The patient is having 10/10 pain with burning and limitation of her walking distance. The records do not indicate that more serious conditions have been ruled out. Additionally, the compression stockings provided no relief, which is evidence that treatment of the patients spider veins would not address the described symptoms. The requested treatment of the spider veins would primarily have a cosmetic benefit and are not to treat a functional impairment or severe symptoms. All told, the requested procedure is not reconstructive in nature and not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tadalafil 11 mg troche daily. There is sufficient support for the requested medication in this patients case. Phosphodiesterase type 5 inhibitors have been shown to be effective following radical prostatectomy. Daily phosphodiesterase type 5 inhibitors are generally recommended. This patient was appropriately placed on daily tadalafil. Tadalafil troche is efficacious for erectile dysfunction in this clinical setting. Therefore, the requested tadalafil 11 mg troche daily is medically necessary 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 urology 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: The patient has requested reimbursement for esophagogastroduodenoscopy (EGD) procedure. Clinical guidelines recommend endoscopy for investigation of upper gastrointestinal symptoms such as GERD disease and dyspepsia when these symptoms are refractory to proton pump inhibitor taken properly for one to two months without response. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that EGD is warranted if an appropriate trial of therapy for a suspected benign digestive disorder has been unsuccessful. The American College of Gastroenterology (ACG) guidelines support EGD if symptoms have been refractory to proton pump inhibitor for at least one month. The ACG do not recommend endoscopy in patients below age 60, even when alarm symptoms are present. These recommendations are concordant with current medical literature. In this case, the records provided for review do not document an attempt of proton pump inhibitor for at least one month prior to EGD. Moreover, there is a lack of evidence of an accepted indication for the use of EGD. For these reasons, the EGD procedure was not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of 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 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

An enrollee has requested reimbursement for urinary tumor marker testing (Cxbladder Detect Test). Molecular testing for the detection of bladder cancer remains an adjunct to standard evaluation, which includes cystoscopy, urine cytology, and possible imaging. Urinary biomarkers including the Cxbladder Detect may be useful in increasing the sensitivity of diagnosis, which might reduce the need for frequent imaging with computed tomography (CT) and endoscopy. However, urine messenger RNA testing to detect gene expression for bladder cancer cells has not been demonstrated in large randomized controlled clinical trials to improve patient health outcomes when compared with the current standard of care. The recommended course of action for patients with microhematuria continues to be contrast enhanced imaging of the urinary tract and cystoscopy. This patients records demonstrate the presence of microhematuria. However, a renal ultrasound in revealed normal findings. All told, the urinary tumor marker testing (Cxbladder Detect Test) was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the urinary tumor marker testing (Cxbladder Detect Test) was not likely to be more beneficial for evaluation of the patients 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 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

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the patient has identified delays in his receptive speech of 44% and in his expressive speech of approximately 56%, with mild cognitive delays. Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, in this patients case speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested Oxycontin 80mg. for treatment of his chronic low back pain.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient was found to be non-compliant with cocaine in his system and Oxycontin was discontinued. However, the patient was continued on Percocet so that he would have medication for his chronic pain without placing him at risk for significant detoxification or adverse events. Moreover, the peer-reviewed literature cited above does not support the continuation of Oxycontin in this clinical setting. Manchikanti and colleagues indicate the available evidence is weak for pain relief combined with improvement in functional status for longer term opiate use in chronic non-cancer pain. In sum, the records do not support long-term continued use of this medication for this patient. Therefore, the requested medication is not considered medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee requested combination therapy consisting of Sovaldi and ribavirin for medical treatment of the enrollees hepatitis C genotype 3a. Findings:  Three physician reviewers found that the efficacy of Sovaldi has been established in subjects with HCV genotype 1, 2, 3 or 4 infections, including those with hepatocellular carcinoma awaiting liver transplantation and those with human immunodeficiency virus (HIV) coinfection. The proposed treatment is considered the standard of care for the treatment of the patients with HCV genotype 3, and is expected to be beneficial for this patient by potentially curing her infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. The combination therapy with Sovaldi and ribavirin has been approved by the U.S. Food and Drug Administration (FDA) based upon the large trial on genotype 2 and 3 patients (Zeuzem, et al). Given the available data supporting the safety and effectiveness of the requested medication regimen of Sofosbuvir and ribavirin for 24 weeks, the requested combination therapy is medically necessary for treatment of this patients medical condition.