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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom molded foot orthotics. Findings:  The physician reviewer found that the enclosed information, the requested custom molded foot orthotics are supported as medically necessary for treatment of this patient. The medical documentation reports that this patient is being treated for painful left plantar fasciitis and overpronation of bilateral feet. The patient has failed to achieve pain relief with numerous conservative treatment modalities including non-steroidal anti-inflammatory drugs (NSAIDs), over-the-counter orthotics, icing, stretching, and corticosteroid injections. The patients provider has recommended treatment with custom molded foot orthotics. As noted in the medical literature, custom molded orthotics are a mainstay in the treatment of patients with painful plantar fasciitis. Lewis and colleagues found that, Studies have shown that orthotics, both prefabricated and custom fitted, reduce pain and improve function in adults with acute plantar fasciitis with few risks or side effects. The provider noted that this patient has a history of painful plantar fasciitis as well as a pes planus foot structure and over pronation. The requested custom functional orthotics will help to reduce overpronation of the foot as well as support and reestablish a medial arch. These two activities are noted to reduce stress and strain from the plantar fascial origin and reduce plantar fasciitis pain. For these reasons, the requested custom molded foot orthotics are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is licensed D.P.M., board certified in podiatric surgery, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 19-year-old male enrollee has requested reimbursement for urgent care services.  Findings:  The physician reviewer found that the patient presented to the urgent care center for evaluation of pain in his right shin that he had been experiencing for one week. The patient noted that he had been playing club rugby recently and doing a lot of running. However, he did not note any specific injury to the right lower leg, he denied numbness or weakness, and no pain level was documented although it was noted that the patient was in no acute distress.  He had been applying ice packs directly to the shin. The physical examination revealed a first degree burn of the skin of the anterior tibial area but no underlying bone pain with actively standing on his heel and toes.  Bilateral pes planus (flat feet) was noted.  No x-rays were performed.  He was diagnosed with shin splints in the right lower leg and bilateral pes planus.  He was discharged from the Urgent Care Center with instructions to use Advil for pain, to refrain from running, and to follow up with a podiatrist. The patient states that he was subsequently diagnosed with a right tibia fracture by another provider. The patient has requested reimbursement for the urgent care services which the Health Plan has denied.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines urgently needed services as a those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area.Review of the submitted documentation reveals that although the patients level of pain was not documented in the medical records provided, the records note that the patient was in no acute distress. There was no specific injury to cause one to think that a bone had been fractured, and the patient was bearing weight without difficulty. In addition, the patient indicated that he had been obtaining temporary relief from Motrin. A prudent layperson would not have thought that urgent medical attention was necessary to prevent serious deterioration of health, injury or complication of an existing condition. Treatment could have been delayed until the patient returned to the plan's service area or a provider was found in the new service area. Thus, the patients symptoms on the date in question did not meet prudent layperson criteria for urgent care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 70-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her invasive ductal carcinoma of the right breast.  Findings:  Two physician reviewers found that the Centers for Medicare and Medicaid Services (CMS) suggest that FDG-PET is only indicated as an adjunct to other imaging studies for staging, restaging in breast cancer patients or monitoring tumor response to treatment for patients when a change of therapy is being considered. Similarly, Kelloff and colleagues do not recommend FDG-PET in the routine surveillance of patients with a history of breast cancer. With regard to this patient, there is no indication that her provider is contemplating a change in her course of treatment depending on the results of the PET scans. Further, there are no findings in the records suspicious for recurrence to warrant a PET scan at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old female with a history of endometrial cancer. The patient was initially diagnosed in 1999. Since her surgery, the patient has been followed with CT scans and serum markers. The CT scans have been negative for recurrence with the last exam performed in October 2002. The serum 19-9 has increased from 63 to 74.4. The patients provider has recommended a positron emission tomography (PET) scan to rule out active metastases. The Health Plan has denied authorization for the requested PET scan on the basis that it is not medically necessary for evaluation of the patients medical condition.The Centers for Medicare and Medicaid Services (CMS) does not list endometrial cancer as an approved indication for PET scanning. Though some studies evaluating PET scanning and endometrial cancer have shown the PET scan can be of value in detecting recurrent disease, the number of patients in these studies has been relatively small. At this time, PET scanning for endometrial cancer is not a standard imaging exam. Follow-up CT scan of the chest/abdomen/pelvis is the exam of choice. Therefore, I have determined that the requested PET scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior Orthovisc injections received four years ago. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections for both knees are medically necessary for the treatment of this patient.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested IgG Babesia microti, Ehrlichia chaffeensis IgG, IgG anaplasma phagocytophilum, IgG EBV, IgG HHV6, Babesia, Ehrlichia, anaplasma, EBV, HHV6, antibiotic therapy and hyperbaric oxygen therapy for evaluation and treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has no evidence of any current infection.  He has none of the infections for which he is requesting therapy.  There is no evidence that the requested prolonged antibiotics or hyperbaric oxygen therapy are of use in any of the infections for which he is requesting therapy.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested IgG Babesia microti, Ehrlichia chaffeensis IgG, IgG anaplasma phagocytophilum, IgG EBV, IgG HHV6, Babesia, Ehrlichia, anaplasma, EBV, HHV6, and hyperbaric oxygen therapy are not medically indicated in this patients case.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation and 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 infectious 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for treatment of the enrollees mixed hyperlipidemia. Findings:  The physician reviewer found that the request for Repatha has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided the patient is a male with hyperlipidemia and statin intolerance but no documented obstructive coronary disease. Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. In this case, the patient does not fit any of those criteria. There is no documentation to support a history of familial hypercholesterolemia since this diagnosis requires elevated LDL cholesterol levels that significantly exceed 180 mg/dL in combination with physical exam findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epidural injection for treatment of the enrollees back pain. Findings:  The physician reviewer found that evidence based medical guidelines recommend lumbar spine epidural steroid injections with use in conjunction with active rehabilitative efforts. The literature supports these injections as a possible option for short term treatment of radicular pain, pain in dermatomal distribution with corroborative findings of radiculopathy. The criteria for the use of epidural steroid injections include documentation of radiculopathy with objective findings on examination and corroborated by imaging studies and/or electro-diagnostic testing, and initially unresponsive to conservative treatment. Current peer reviewed literature concludes that both epidural injections with steroids or with local anesthetic alone provide significant pain relief and functional improvement in managing chronic low back pain secondary to lumbar spinal stenosis. This patient presents with persistent moderate to severe low back pain radiating into the right anterolateral thigh to the anterior knee. Signs/symptoms are consistent with spinal stenosis. Clinical examination findings have documented motor deficits and reflex changes consistent with imaging evidence of multilevel lumbar stenosis and plausible nerve root compromise, most severe at the L3-4 and L4-5 levels. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Therefore, the requested injection is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested injection 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 endocrinology, diabetes 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (apremilast) for treatment of her psoriasis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has a history of plaque psoriasis and concomitant hepatitis B infection, on therapy.  The patient is not able to take methotrexate and cyclosporine due to presence of hepatitis B infection. She has already tried and failed therapy with acitretin due to intolerance and itching. Otezla is a newer medication that is not considered to be immunosuppressive. However, there is minimal data to suggest that Otezla is safe for those with hepatitis B. Although considered to be more immunosuppressive, the anti-tumor necrosis factor agents have a longer history of use and there is data in the literature to suggest that their usage may be safer for patients who may have a history of hepatitis B infection. Moreover, there is no documentation as to this patient having tried and failed phototherapy. Therefore, due to the lack of medical evidence supporting the safety of Otezla in patients with a history of hepatitis B, as well as a lack of documentation as to the trial and failure of phototherapy in this patient, Otezla is not medically indicated 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 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: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested the rental of a roll-about knee scooter for treatment of her medical condition status-post Achilles tendon surgery. Findings:  The physician reviewer found that strict non-weight bearing precautions are important following this surgery to avoid complications such as re-rupture of the tendon (Molloy and Wood). The patient states that she could not use a walker, because she believed that the use of a walker requires using both feet. However, her strict non-weight bearing precautions could have been maintained using the walker by keeping the involved lower limb off the ground. For patients unable to maintain strict non-weight bearing precautions with crutches or a walker (due to upper body weakness or general deconditioning), strict non-weight bearing precautions can be maintained with the use of a wheelchair. The use of a roll-about knee scooter is an alternative means of maintaining non-weight bearing precautions of one lower limb, but it is not generally medically necessary if crutches, a walker and a wheelchair are available. Notably, this type of assistive device has not been formally studied in the medical literature. It is not a part of published post-operative rehabilitation protocols following Achilles tendon rupture repair (Strom and Casillas).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Bioness L300 foot drop system electrical stimulation (FES) device for treatment of the enrollees foot drop secondary to multiple sclerosis (MS).  Findings:  Two physician reviewers found that evidence based research and medical literature support the use of FES in this patients case. This patient has had MS, with residual spasticity and foot drop. The patients foot drop continues to impair gait, with frequent falls despite use of an ankle foot orthosis (AFO). The medical literature shows that foot drop gait is known to be inefficient, with increased fatigue and slowed walking speed. Research on the use of FES has shown potential benefit in speed of walking and oxygen uptake in patients with spasticity from chronic central nervous system (CNS) lesions, as occur in MS, stroke, traumatic brain injury, or spinal injury. Studies have also shown potential for neural plasticity, with functional gains maintained after discontinuation of FES. In this patient, a trial of FES demonstrated benefits beyond standard therapy with an AFO, and thus FES is likely to be more beneficial than standard modalities.   Final Result: Two reviewers determined that the requested device is 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: One reviewer is board certified in neurology and is actively practicing. One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. One reviewer is board certified in physical medicine and rehabilitation 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: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested surgery to correct the asymmetry and excessive tissue in the right forearm and underarm for treatment of her excess tissue. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a weak and stiff right shoulder due to trauma and post-traumatic surgery.  The medical records document obesity.  Photographs show excess skin and fat around both arms, right greater than left.  The skin is normal, and there is no abnormality such as excess upper arm skin hanging below the level of the elbow or lymphedema. The appearance is as expected for a patient with this body mass index.  Thus, the asymmetry and excessive tissue in the right forearm and underarm do not constitute an abnormal structure of the body.  Further, the requested surgery would not improve function or create a more normal appearance than is present.  In sum, the requested surgery to correct the asymmetry and excessive tissue in the right forearm and underarm is not medically necessary and is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested Amitiza for the treatment of her chronic constipation. Findings:  The physician reviewer found that this patient has been refractory to all over the counter laxatives. She had been on Zelnorm in the past (which is only available under IND program) and Miralax, and had not achieved any relief with these medications. Based on the results of the above studies, she fits the clinical profile of the patients with idiopathic constipation that should respond to Amitiza, and therefore, the medication should be approved for her condition.