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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prescription medication, Treximet. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient has had migraine headaches for many years as confirmed by her medical record.  The medical literature and medical evidence regarding Treximet show that Treximet has different pharmacokinetics and tolerability profile when compared to the generic sumatriptan and naproxen alone. The literature also indicates that Treximet has fewer side effects and patients experience a greater probability of sustained freedom from pain. The patients description of her results from Treximet is in line with the data provided in the medical literature.  She has been using Treximet as her abortive therapy for treatment of her migraine headaches for years, and this has proven to be effective. The records also show that she has tried and failed other medications. All told, Treximet is medically necessary for the treatment of this patients medical condition.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 neurology 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

The patient is a 53-year-old male with adenocarcinoma of the prostate, reported as clinical stage T1c. In March 2006 his PSA level was 4.9. An ultrasound guided biopsy was performed in April 2006 and one of the five cores from the left side of the prostate revealed a Gleason score of 3+3 (total 6) adenocarcinoma of the prostate; the five cores from the right side were benign.  Surgical treatment with radical prostatectomy was recommended. The Health Plan offered either open radical (retropubic) prostatectomy or laparoscopic radical (retropubic) prostatectomy.  The patient requested authorization for a laparoscopic radical (retropubic) prostatectomy with robotic assistance performed by a non-Plan provider.  The Health Plan determined the robotic assisted procedure was not medically necessary, and denied the request.Radical prostatectomy is the appropriate surgical treatment for a 53-year-old male with clinical state T1c prostate adenocarcinoma, a Gleason total of 6, and a PSA of 4.9.  This would typically represent a localized prostate cancer that can be cured with surgical removal. There are currently four acceptable and recognized surgical approaches for removal of a localized prostate cancer. They are:1.Open radical (retropubic) prostatectomy;2.Laparoscopic radical (retropubic) prostatectomy;3.Robotic assisted laparoscopic radical (retropubic) prostatectomy; and 4.Radical (perineal) prostatectomy.All of these techniques offer good results in terms of complication rates and survival statistics when capably performed by a qualified and experienced surgeon.  It should be noted however, that truly long-term outcome data for the laparoscopic surgeries, whether robotically assisted or not, are not yet available.  There is no medical basis for objection to any of these surgical approaches, and each has its advocates and relative advantages. In terms of complication rates and survival statistics, the two surgical alternatives offered by the Health Plan, open radical (retropubic) prostatectomy and laparoscopic radical (retropubic) prostatectomy (without robotic assistance), are fully acceptable alternatives to the laparoscopic radical (retropubic) prostatectomy with robotic assistance requested by the patient. Therefore, I have determined laparoscopic radical (retropubic) prostatectomy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test to gauge risk for thyroid cancer. Findings:  The physician reviewer found that the cytopathology of the patients 1.8 cm thyroid nodule was consistent with FLUS. The risk of malignancy is 5-15% in FLUS . The American Thyroid Associations guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. If the genetic test is suspicious, the risk of malignancy increases to 40% . The risk of malignancy decreases to less than 6% with benign findings. In this case, the patient has a solid thyroid nodule measuring 1.8 cm with worrisome features and the cytopathology was consistent with FLUS. The result of the Afirma from the same specimen was benign. This information was important to determine the decision whether to perform a thyroidectomy and may prevent the need for a repeat biopsy or diagnostic hemi-thyroidectomy. There are multiple peer reviewed scientific articles supporting the benefits of genetic testing of thyroid nodules. Moreover, the Afirma test is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network (NCCN) guidelines. For the reasons provided, the gene test to gauge risk for thyroid cancer was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Skilled Nursing Facility (SNF) services.The submitted documentation does not support that the Skilled Nursing Facility (SNF) services at issue were medically necessary. Spine surgery may be indicated in cases of refractory back pain with indication of pathology that is amenable to surgical intervention. Multidisciplinary rehabilitation is often indicated postoperatively when there are issues such as significant functional decline, poorly controlled pain, and wounds that require close monitoring.In this case, the patient underwent multiple spine surgeries for chronic back pain. Patient had multiple complications and had persistent lower limb weakness with functional decline. The patient was transferred to a skilled nursing facility for reconditioning and ongoing wound care. patient participated in therapies and made some progress, but  plateaued at a level where help for basic self-care tasks were needed. The patients mobility was limited, and required supervision at least, if not physical assistance at times. Given underlying impairments and plateau in functional gains, patient would not have been expected to improve further functionally in a predictable and significant manner that would have altered the amount of assistance required in the community on a practical basis. The patient had a back wound that was chronically requiring wound VAC dressing care, but there were no indications that this could not have been continued on an outpatient basis. The patient otherwise had multiple chronic medical conditions, but none that required ongoing inpatient level medical and nursing care. The patient had plateaued at a level where further care was custodial and Skilled Nursing Facility (SNF) services were not medically necessary. Further rehabilitation efforts could have been provided in the community, or at a custodial level facility, if needed due to environmental barriers and/or insufficient caregiver availability, willingness or ability. Accordingly, the Skilled Nursing Facility (SNF) services at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 37-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar I disorder. Findings:  Three physician reviewers found that peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile along with case selection for benefit of repetitive TMS.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. They noted that continued trials are required. Lam and colleagues concluded that for patients with treatment-resistant depression, TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before TMS can be considered as a first-line monotherapy treatment for treatment-resistant depression.  Gershon and colleagues also reported positive responses of TMS as an antidepressant treatment, but noted continued need for verification and standardization of best practices and type of patient that would benefit. All told, the superior efficacy of the requested services in this clinical scenario has not been established at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old man with hepatitis C and hepatocellular carcinoma since at least 2003. He was judged non-resectable and treated with chemoembolization. He has since been treated with octreotide, but has been found to have progression of his tumor and biopsy proven extra-hepatic nodal metastasis at endoscopic ultrasound. The submitted materials indicate that the patient is being considered for liver transplant.  The patient is currently ambulatory. He is requesting authorization and coverage for chemoembolization. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.The patient has metastatic disease and there is no evidence he has been evaluated by a transplant center and determined to be an appropriate candidate for liver transplant. He has non-resectable hepatocellular carcinoma, and the question is whether transcatheter chemoembolization is necessary medical treatment for this condition.  The topic is the subject of controversy because the available randomized controlled trials have yielded conflicting results. The studies available to date do not favor transcatheter chemoembolization for patients with metastatic disease.  The available positive clinical trials had strict criteria including Okuda 1 and 2 patients who did not have metastatic disease.  Although length of survival was increased in these carefully selected patients, there is no evidence that transcatheter chemoembolization is medically necessary or superior to systemic treatment for patients such as this patient with metastatic disease.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A twenty-one year-old female who sustained a gunshot wound to her neck is seeking reimbursement for the air ambulance transport.Reviewers Findings:The reviewing physician found that the patient required transfer to another facility where she could receive clinically appropriate and necessary treatment.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 10-year-old male enrollee requested authorization and coverage of continued occupational herapy for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees motor delays.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Testopel 75 mg x 12 implantable pellets every four months. This patients medications include Dilaudid, Opana and Cymbalta, all of which are associated with decreased libido and erectile function. Alternate sources of pain management would improve the patients testosterone levels and potentially improve his symptoms. There is significant literature that testosterone replacement is warranted in cases of opioid-induced hypogonadism (Coluzzi, et al.). However, the patients records do not document the chronically low testosterone level that warrants replacement. Based on the available documentation, the requested Testopel 75 mg x 12 implantable pellets every four months are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

The parent of a one-year-old male enrollee has requested Protopic for treatment of the enrollees eczema and xerosis. Findings:  The physician reviewer found that a study by Reitamo and colleagues demonstrated the safety of using topical Protopic ointment in pediatric population. The authors found that there is little systemic absorption of topical Protopic, leading to very low exposure to the medication. Moreover, Breuer and colleagues discussed the safety of Protopic with follow-up of up to four years. Given that this patient with severe eczema has failed numerous treatments including topical corticosteroids, he should be treated with Protopic. Further supporting this conclusion is that the patient was already trialed on Protopic and experienced an almost complete response and tolerance to the medication. Protopic has allowed this patients eczema to clear and in turn he has thrived physically, emotionally and socially. Thus, based upon the above evidence, the requested Protopic 0.03% ointment is medically necessary and the use of this medication should be approved for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 16-year-old male enrollee requested authorization and coverage of maxillary osteotomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees jaw deformity.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested substance abuse residential treatment center (RTC) services provided and substance abuse intensive outpatient program (IOP) services for treatment of his substance abuse.   Findings:  The physician reviewer found that the substance abuse intensive outpatient program services provided from 2the time period specified were not medically necessary for treatment of the patients medical condition. The patients last drink was on the date specified, his comorbid anxiety disorders were controlled on medications and he denied suicidal/homicidal ideation and was not a danger to others. While his relationship with his wife was impaired due to his drinking, she was supportive of him in his recovery, as was his mother. He attested to improved mood in terms of his depression, and a lower level of anxiety. He participated actively in all aspects of the program and regularly attended 12-step meetings, demonstrating motivation to change his behavior. He became more comfortable in sharing and participating in groups, as well as expressing his feelings regarding his family. He was developing coping skills and identifying triggers towards drinking. Changes in his medication regimen could have taken place in an office based setting. He had improved to the point that his treatment could have been stepped down to a lower level of care and been provided in an office based setting as well, with additional support in the form of 12-step programs and connecting with a sponsor. Thus, he did not meet the medical necessity criteria for substance abuse intensive outpatient program services from the time frame specified. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

enrollee has requested authorization and coverage for Infini laser treatments. Infini radiofrequency microneedling laser system delivers controlled radiofrequency energy to break down scars to deep skin layers. This bipolar radiofrequency system generates fractional zones of electrothermal damage deep in the dermis, surrounded by areas of undamaged tissue under a more-or-less intact epidermis. These areas of damage in the dermal matrix induced a vigorous wound healing process supported by the surrounding undamaged tissue and lead to the synthesis of new collagen and elastin, dermal remodeling and replenishment of hyaluronic acid. Microneedle fractional radiofrequency also showed improvement of acne scars and large facial pores with less adverse events than fractional lasers. In a study, 20 patients were treated with Infini lasers for atrophic, burn, photoaging and acne scars. Patients were examined one month after the last session. Efficacy and patients satisfaction were assessed using a ten-point score. Efficacy was also evaluated by a physician on a ten-point score, measuring global improvement on skin texture, depending on the condition treated. The mean satisfaction of treated patients was very high. The balance between efficacy and a well-tolerated procedure was highly favorable. No infectious complication was reported despite the absence of antibiotic and antiviral treatment. It was concluded that the treatment is efficacious in treating atrophic skin scars, with the advantages of minimal post-treatment effects and very high patient satisfaction.There are two questions addressed in this case: (1) Does the requested Infini treatment satisfy Californias criteria for reconstructive surgery?(2) Is the requested Infini treatment medically necessary for treatment of the patients condition?Per Health and Safety Code Section 1367.63, health plans in California must cover reconstructive surgery. Reconstructive surgery is defined as surgery performed to correct or repair an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The surgery must be requested to either improve function or to create a normal appearance (to the extent possible). If the surgery is being requested to create a normal appearance, then the surgery must offer more than a minimal improvement in the appearance of the patient.Here, the patient was noted to have an abnormal structure in the face (scarring, redness). The abnormal structure was caused by disease (systemic lupus erythematosus). The procedure is being requested to create a normal appearance (to the extent possible). Recent studies suggest the Infini laser treatment can offer more than minimal improvement. Therefore, California criteria for reconstructive surgery have been met. Additionally, there are no other standard treatments that are more likely to improve the patients facial redness and scarring. Clinical evidence suggests that this treatment is efficacious in the treatment of this patients condition. Therefore, the requested services are also medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested for consultation  for treatment of her inflammatory breast cancer (IBC).  Findings:  The physician reviewer found that inflammatory breast cancer is a rare type of breast cancer, representing only 2% to 3% of all breast cancers diagnosed annually in the United States. The literature also indicates that it is a fast-growing breast cancer and can be misdiagnosed, as was apparently the case with this patient. The literature also states that starting treatment as soon as possible is important.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prolotherapy. The current peer-reviewed medical literature does not support treatment with prolotherapy for posterior tibial tendon dysfunction. There are a few case reviews that reported positive findings, but there is a need for further study to establish the long-term outcomes and side effects. Overall, the evidence is limited on prolotherapy for use in this clinical setting. Given these findings, the requested prolotherapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested prolotherapy is 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 requested prolotherapy is 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 podiatry 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.