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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injections to both knees for osteoarthritis. Findings:  The physician reviewer found that she has had bilateral knee pain, right worse than left, for the last few years. She received cortisone injections to her knees.  At a visit with her orthopedist she indicated the injections provided relief for many months but the pain had worsened over the last few months. An x-ray of the bilateral knees showed tricompartmental degenerative changes bilaterally, most pronounced in the patellofemoral compartments, right slightly greater than left, and small right and tiny left effusions.  The physician discussed conservative management options, including non-steroidal anti-inflammatory drugs, activity modifications, cortisone injections and viscosupplementation. She elected to proceed with cortisone injections. At the next visit, the enrollee reported continued pain and requested a trial of Orthovisc, which was administered then and at two subsequent visits. When she was seen again, she indicated significant knee pain was impacting her activities of daily living and activity.  The treatment plan included conservative treatment and cortisone injections. A study in the medical literature indicates the use of any intraarticular hyaluronic acid formulation is not recommended due to the lack of robust evidence demonstrating benefit. There has been a longstanding debate and conflicting data across trials and analyses regarding the benefit of viscosupplementation. Evidenced-based studies do not demonstrate that hyaluronic acid injections result in a delay of knee replacement. Additionally, studies show that it does not show superiority over other treatments; including placebo. Review of the record indicates the enrollee had previous benefit from hyaluronic acid injections, but the benefit was mild and was wearing off in a short time. Guidelines do not recommend the use of hyaluronic acid injections.  Final Result: The reviewer determined the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedics and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Concerta.Findings: A study has concluded that adult ADHD is a prevalent but under-recognized disorder in psychiatry. Failure to identify and treat adult ADHD is linked to negative outcomes. Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention.In this case, the patient has been diagnosed with adult ADHD previously and has benefited from treatment with Concerta. The submitted records are consistent with a lack of misuse of the stimulant, and they reflect a clear benefit in her ADHD symptoms from the medication regimen. The patient has benefited from a low dose of Concerta, with her medication dosage remaining stable for 18 years, and without any medication adverse effects. The patients symptoms have been stable on the medication, and she has experienced worsened functioning in work and home without the medication. The requested medication addresses the specific needs of the patient, for the purpose of treating her diagnosed adult ADHD. Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention, and treatment with the requested medication is in accordance with the generally accepted standards of mental health care. Treatment with the requested medication is clinically appropriate and it is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the requested medication Concerta is medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the requested medication is medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization and coverage for intensive outpatient program services provided from 8/23/18 forward. The Health Plan denied this request, indicating that the requested service were not and are not medically necessary for treatment of the enrollees behavioral health conditions.The submitted documenation supports the medical necessity of the requested services. The American Psychiatric Association guideline for major depressive disorder notes that admission to an intensive day program, may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. This patients depression is complicated by his new onset dementia and was not able to be managed as an outpatient, thus necessitating admission to the detoxification/rehabilitation program. Group therapy notes demonstrated a lack of insight into the nature of his difficulties. This, along with the change in his behavior to being easily angered, represent significant departures from his baseline. As it was not resolved in the detoxification/rehabilitation program, step down to the next level of treatment, IOP, is consistent with standards of good medical practice and available evidence. Therefore, the requested services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services were and are medically necessary for treatment of the patients behavioral health condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested for CyberKnife Therapy (CyberKnife Stereotactic Radiation or CyberKnife Robotic Surgery) for treatment of his Primitive Neuroectodermal Tumor (PNET) with metastatic growth.   Findings:  Three physician reviewers found that Cyberknife treatment is an emerging modality which has been used for cancer of the prostate, lung, liver, etc. There is no data in the literature suggesting superior outcomes using Cyberknife for PNET. The patient has a very large tumor measuring approximately 12x10 cm. With preoperative treatment utilizing radiation, a very large area has to be treated with moderate doses of radiation. I do not see any benefit of Cyberknife in this situation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for NeuroPace RNS brain neurostimulator. Anti-epileptic drugs are the first-line therapy for epilepsy. Patients who do not become seizure-free after using two appropriately chosen anti-epileptic drugs at therapeutic doses are unlikely to be seizure-free by using medications alone, and the epilepsy is termed pharmacoresistant. Additional treatment options include diet therapy, surgical resection, and neurostimulation (Starnes, et al.). A responsive neurostimulation (RNS) device is a closed-loop device that delivers targeted stimulation to seizure focus and abort seizure activity. Researchers reported the successful treatment of a patient with a seizure onset in the eloquent cortex of the left temporal neocortex, with a reduction from daily seizures to auras only a few times per week at the six-month follow-up. Similarly, another study reported using RNS in a patient with independently hemispheric seizure onset, and in a patient with seizure onset in the eloquent cortex in the left frontal and parietal lobes. The authors found greater than 80% reduction in seizure frequency in both patients. In this case, the patient has intractable focal epilepsy. He underwent evaluation at an epilepsy center and his work-up demonstrated a right central lesion. The patient has failed multiple medications to control his seizures. Given the support in the medical literature, the requested subdural implantation of a NeuroPace RNS brain neurostimulator (CPT code 64568) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested subdural implantation of a NeuroPace RNS brain neurostimulator (CPT code 64568) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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 25-year-old female enrollee has requested residential treatment services for treatment of her alcohol dependence. Findings:  The physician reviewer found that this patient has a long history of substance abuse problems.  She has been to numerous treatment centers for a variety of substance and psychiatric issues. She had serious difficulty maintaining her sobriety in the past. There is limited information in the submitted progress notes as to her status in treatment. The notes largely consist of statements about her group attendance and other brief statements. Based upon the submitted documentation, her motivation was limited, and this is considered a major factor in treatment success. In cases such as this, an evidence-based instrument such as the Level of Care Utilization System is useful in determining the necessary level of care to insure the level of care meets individual needs safely and effectively, in the least restrictive setting possible.  Based upon these guidelines, medically monitored residential services were medically indicated at the time of admission to the residential treatment center as the patient was at moderate risk of harm, her functional status was seriously impaired, and she had significant co-morbidities. The current minimum standard for this level of care is four weeks of treatment on an inpatient basis. It appears this length of treatment was warranted for this patient. A treatment length longer than this is not supported by the submitted documentation. Thus, residential treatment services during the initial four weeks were medically indicated. The medical necessity of residential treatment services provided after the initial four weeks has not been established, and the patient could have been treated safely and effectively at a less restrictive setting during these dates.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic test for evaluation of the enrollees risk for cancer. Findings:  The physician reviewers found although this patient does not have a personal history of cancer the patient has an ovarian cyst and a strong family history of cancer, especially on paternal side where they are diagnosed at a young age. The patient also has family members on mothers side with cancer. Thus, The patient meets criteria per the National Comprehensive Cancer Network (NCCN) guidelines for testing for BRCA1 and BRCA2. Final Result: Two of three reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested AmniSure testing for evaluation of her premature labor. Findings:  Two physician reviewers found that AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. The study by researchers found AmniSure to be highly accurate in diagnosing fetal membrane rupture. In this case, nitrazine and fern testing was not available. Since other standard testing was not available, the AmniSure testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld

A female enrollee requested residential treatment center services for treatment of her depression and anorexia nervosa.  Findings:  The physician reviewer found that progress notes from the patients treatment indicate the residential treatment center services at issue were not medically necessary. She was experiencing some depressive and anxious symptoms, but these symptoms were mild-to-moderate, and did not require the intensity of residential treatment level of care. She was very cooperative in treatment, showed insight into her need for treatment and did not demonstrate any dangerous behaviors. The patient was going for visits outside the treatment center and had appropriate behaviors in public. All told, residential treatment center services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xeljanz (5 mg, twice daily). The current medical evidence supports the requested medication in this clinical setting. There is a large body of growing evidence that Janus kinase (JAK) inhibitors, such as tofacitinib, are safe and efficacious for the treatment of alopecia areata/totalis. The provider has recommended the JAK inhibitor, tofacitinib. The patient has severe alopecia areata with 75% involvement of the scalp. Per the submitted records, the patient has tried and failed clobetasol, squaric acid, topical tofacitinib, anthralin, and intralesional Kenalog. There is sufficient support for the requested medication in this patients case. Therefore, the requested medication, Xeljanz (5 mg, twice 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 dermatology 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 external mobile cardiovascular telemetry. There is a lack of data in current medical literature supporting the use of real-time remote cardiac monitoring and definitively demonstrating its superiority to standard loop monitoring or event monitoring. In this case, the records did not document symptoms suggesting potentially life-threatening arrhythmias that would theoretically necessitate real-time monitoring for a possible immediate medical intervention. Therefore, external mobile cardiovascular telemetry was not likely to have been more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the external mobile cardiovascular telemetry at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewers 2 and 3 are board certified in board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 3-year-old male enrollee has requested one-hour sessions of individual speech therapy (up to two sessions per month) for treatment of the enrollees autism and speech delay. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Speech therapy is medically necessary for this patient with autism spectrum disorder (ASD) and a history of expressive language delays with socialization and pragmatic deficits. Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Volkmar and Wiesner).  Language skills make a significant difference in the ability of children to control their environment especially those individuals with social skills deficits (Goldstein). This patient is likely to benefit from speech therapy as part of a dedicated intervention program. Goldstein reviewed communication intervention for autism in peer-review research articles published over the past 20 years. The evidence supported the claim that effective interventions exist to teach communication skills to children with autism (Goldstein). Individualized speech therapy at a frequency of two one-hour sessions per month is medically reasonable and appropriate for this patient. All told, the medical necessity of the requested therapy has been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients diagnosis is type 1 diabetes. The patient is currently being managed with a Medtronic 670 G insulin pump. The patients hemoglobin A1c was 7.5 % and her body mass index (BMI) was 22. She was started on Victoza therapy and was on liraglutide (Victoza) for six weeks, with noted improvement in postprandial blood sugars, decreased glycemic variability, and no episodes of hypoglycemia.The primary effects of glucagon-like peptide-1 (GLP-1) agents in type 1 diabetic patients are improved glycemic control, decreasing episodes of hypoglycemia and glucagon secretion, lowering glycemic excursions, and weight loss. Researchers concluded that treatment with Victoza in type 1 diabetes reduces insulin dose with improved or unaltered glycemic control. However, there is lack of large scale randomized controlled studies that have evaluated GLP-1 agents in type 1 diabetic patients. Further, GLP-1 agonist Victoza has been approved by the U.S. Food and Drug Administration (FDA) for patients with type 2 diabetes. As this patient has type 1 diabetes, Victoza therapy is not medically necessary for treatment of this patients medical condition.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 endocrinology and metabolism, 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 40-year-old female has requested a computed tomography (CT) scan of the head  for evaluation of chronic headaches.  Findings:  The physician reviewer found that there are many possible causes for headaches, and only a few of those causes can be found on CT scans. The progress note that was provided for review includes no physical or historical evidence to suggest that a CT scan is the next logical step in this case.