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

 Case Summary:  The enrollees representative is requesting authorization and coverage for the requested medication, Nutropin AQ Nuspin. The endocrinologist has prescribed growth hormone therapy for this enrollee. The enrollee is diagnosed with idiopathic short stature (ISS). The medical literature indicates classic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency. The diagnosis of GH deficiency is based on auxological, biochemical and sometimes radiological findings. The auxological criteria upon which a biochemical evaluation is to be initiated include 1) severe short stature, defined as a height more than 3 SDS below the mean; 2) height more than 1.5 SDS below the midparental height; 3) height more than 2 SDS below the mean and a height velocity over one year more than 1 SDS below the mean for chronological age, or a decrease in height SDS of more than 0.5 over one year in children over two years of age; 4) in the absence of short stature, a height velocity more than 2 SDS below the mean over one year or more than 1.5 SDS sustained over two years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml. Review of the record indicates the patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. FDA approval for this indication is for non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The record indicates the patient does not have a pre-treatment height less than or equal to -2.25 SDS. Therefore, the patient does not meet idiopathic short stature criteria. There is insufficient evidence in the record substantiating the patient meets any nationally accepted criteria for use of growth hormone. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric endocrinology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for nasopharyngoscopy with dilation of the eustachian tubes. Findings:  The physician reviewer found that Balloon dilation of the eustachian tube has been established as a safe and effective procedure for the treatment of eustachian tube dysfunction and obstructive otitis media. The American Academy of Otolaryngology guidelines related to the procedure, indications, and outcomes note that balloon dilation of the eustachian tube is appropriate for patients who have failed medical management, such as in this case. Conservative medical therapy in this clinical setting may consist of daily or twice daily nasal corticosteroid sprays, saline rinses and irrigations, oral antihistamines, short-term decongestant usage, and occasional short-term oral steroids and auto-insufflation. Notes documented that the patient had effusion and balloon dilation of the eustachian tube was attempted. While balloon dilation of the eustachian tube was more likely to have been more beneficial than other treatments for the right ear, the submitted records did not document any indication for the procedure for the left ear. Preoperative audiometry revealed no tympanometric abnormalities and only a sensorineural hearing loss in the left ear. The patients main complaint of hearing distortion in the left ear would not be expected to improve with balloon dilation of the eustachian tube. Therefore, nasopharyngoscopy with dilation of the eustachian tubes of the right ear was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found that a portion of the nasopharyngoscopy with dilation of the eustachian tubes at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Specifically, the reviewers found that nasopharyngoscopy with dilation of the eustachian tubes of the right ear was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the service at issue was 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 partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology  head and neck 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

The parent of an 11-year-old male enrollee has requested Saizen for the treatment of his growth hormone deficiency. Findings:  The physician reviewer found that the patient is likely to have growth hormone deficiency. This may be due in part to the ongoing use of his medications. The patient has shown a brisk response to a trial of growth hormone therapy and is likely to continue to benefit from use of the therapy. In light of the patients likely growth hormone deficiency as well as the positive results he achieved with a trial of hormonal replacement therapy, the continued use of growth hormone is medically appropriate and indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for peripheral nerve/branch injection. Peripheral nerve stimulation is a minimally invasive interventional option for treatment of chronic pain. In this case, given that the patient has neuropathic pain after a stroke that is not well controlled despite a multidisciplinary treatment approach, the requested service is likely to be more beneficial than other available treatment options that the patient has already tried including medication therapy, acupuncture, chiropractic care, and physical therapy. Therefore, a peripheral nerve/branch injection is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested peripheral nerve/branch injection 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 service 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Ibrance for treatment of her breast cancer.  Findings:  The physician reviewer found that patients with advanced cancers whose tumors have progressed on standard regimens will inevitably be treated with agents off of U.S. Food and Drug Administration (FDA) labels. In this case, it is important to evaluate the medical evidence to see if such agents have efficacy and are safe. Palbociclib inhibits cyclin-dependent kinases 4 and 6, which may account for resistance to endocrine therapy. Ibrance is FDA approved for first-line therapy of ER-positive, HER2-negative metastatic breast cancer in postmenopausal women in combination with letrozole. In a trial, 165 patients were randomized to letrozole or letrozole/palbociclib and the latter regimen conferred increased progression-free survival (PFS) of 20.2 months versus 10.2 months, a finding of high statistical significance. In this clinical trial, enrolled patients had no prior endocrine therapy and were postmenopausal. In contrast, another trial enrolled patients who had prior endocrine therapy and allowed both premenopausal and postmenopausal patients. Patients were randomized to fulvestrant or fulvestrant/palbociclib. The latter combination treatment showed significantly increased PFS. This patient matches those evaluated in the clinical trials.  The patient has had a response to the current regimen and it is in her best interest to continue the present therapy. There is sufficient medical evidence to support palbociclib as medically necessary, safe, and appropriate in this clinical setting. 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 oncology and hematology 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: The enrollee has requested authorization and coverage for Transcranial Magnetic Stimulation (TMS) (CPT-90867), (CPT-90868 x 34), and (CPT-90869). Findings:  The physician reviewer found that patients who have tried and not responded to multiple classes of antidepressants, the chance of achieving remission from pharmacotherapy is very low. Multiple randomized controlled trials have supported the safety and efficacy of repetitive transcranial magnetic stimulation (rTMs) therapy for severe depression that is non-responsive to pharmacotherapy. Moreover, rTMS appears to have a moderate effect on reducing symptoms of depression. The Food and Drug administration has approved the treatment of rTMs for patients who have not responded to one adequate antidepressant trial in the current depressive episode. The FDA recommendation is consistent with treatment guidelines from the American Psychiatric Association, Canadian Network for Mood and Anxiety Treatments, and the Royal Australian and New Zealand College of Psychiatrists. In this case, the patient has a history of major depression and has not responded to multiple classes of antidepressants and psychotherapy. Records reflect that the patient had a robust and positive response to rTMS between 2019 and 2020. Treatment with Transcranial Magnetic Stimulation is in accordance with the generally accepted standards of mental health care. Treatment with Transcranial Magnetic Stimulation 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 Transcranial Magnetic Stimulation (TMS) (CPT-90867), (CPT-90868 x 34), and (CPT-90869) 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 services are 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

An enrollee has requested authorization and coverage for the Gardasil 9 vaccine series. Updated recommendations of the CDC Advisory Committee on Immunization Practices (ACIP) for vaccination against human papillomavirus (HPV) note that the public health benefit of HPV vaccination in all adults greater than 26 years of age is minimal, but that shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 to 45 years, because some persons who are not adequately vaccinated might benefit. In this case, the patient is within the 27 through 45 years age range identified by the ACIP. Furthermore, the updated recommendations of the ACIP state that shared decision-making regarding HPV vaccination is recommended for this population. The patients treating provider recommended the Gardasil 9 vaccine series considering the patients history of multiple homosexual sex partners, and one PAP smear which demonstrated low-grade squamous intraepithelial lesion (LGSIL) although biopsy was negative and subsequent PAP smears have been negative. This represents shared decision-making. Therefore, the patient meets the ACIP criteria regarding shared decision-making and regarding the recommended age range. Accordingly, the requested Gardasil 9 vaccine series is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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: Overturned

An 18-year-old male enrollee has authorization and coverage for a knee brace for treatment of the enrollee, who is status post anterior cruciate ligament (ACL) reconstruction. Findings:  The physician reviewer found that the request for an off-the-shelf de-rotation/ACL brace is reasonable and necessary.  The literature is mixed as to the efficacy of prophylactic bracing, but it is reasonable to recognize that in the case of an ACL reconstruction the graft will not regain its full strength for at least six to nine months.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested Avastin therapy for the treatment of his prostate cancer. Findings:  Three physician reviewers found that the patient has androgen-independent, apparently chemo-refractory prostate cancer, metastatic to the bones. Relevant scientific data does not establish the efficacy of Avastin in this setting. Research is ongoing, however the activity of Avastin for prostate cancer is not yet known. The record does not suggest the patient is enrolled in a clinical trial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested intensive outpatient therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that because of the patients dangerous behavior, deterioration and serious functional impairment, intensive outpatient treatment with the multiple therapeutic interventions described is medically indicated. Progress has been noted in the medical record since intensive outpatient therapy was initiated. The level of care at issue is consistent with CALOCUS level of care utilization system guidelines, which provide that intensive outpatient therapy is indicated when there is major comorbidity, serious risk of harm to self or others, moderate to serious functional impairment and a stressful environment. Based on the clinical documentation provided, this patient meets these criteria. The requested therapeutic services are also consistent with American Academy of Child and Adolescent Psychiatry practice guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary frequency.  Findings:  Three physician reviewers found that review of the submitted documentation fails to demonstrate that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than standard therapies. This patient has overactive bladder symptoms and was provided PTNS for treatment of her symptoms. Based on a review of current medical literature there is a lack of adequate studies which distinguish PTNS as a superior form of therapy over conventional therapies such as pelvic floor relaxation exercises or medications like Vesicare and oxybutynin. Thus, percutaneous tibial nerve stimulation was not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee has requested coverage for 12 additional physical therapy (PT) visits for treatment of her lumbago and post-laminectomy syndrome.  Findings:  The physician reviewer found that this patients back condition has persisted despite surgery at the L4-5 lumbar spine such that she was diagnosed with post-laminectomy syndrome. The patient continues to experience back pain despite 12 sessions of PT. Based on the time course of the patients back pain (greater than 6 months of continuous pain), it is deemed that patient has chronic low back pain. Managing chronic low back pain requires a multidisciplinary approach involving medical management and PT. This patient has already been referred to a pain specialist by her primary care physician and undergone a course of PT. Currently, both patient and her physical therapist have indicated that the patient needs more PT sessions to manage her chronic low back pain. Based on medical literature, the patients request for 12 more sessions of physical therapy is appropriate and medically necessary. In a controlled investigation in 1988-1991, Manniche and colleagues showed that intensive back exercises, consisting of 30 sessions distributed during a period of three months significantly reduced low back pain in chronic patients and concluded that an intensive exercise protocol over a prolonged period is crucial for a satisfactory treatment outcome. Similarly, Kankaanpaa and colleagues found that an active rehabilitation program which included 24 exercise sessions during 12 weeks in an outpatient clinic was more successful in reducing pain and self-experienced disability and also in improving lumbar endurance than was the passive control treatment. As this patient has chronic low back pain that has persisted for over three years, the scientific data supports the medical necessity of the requested 12 additional PT sessions in order to manage her chronic low back pain.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female has requested coverage for the brand name medication Ambien for treatment of her insomnia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  Per the medical records, she reported a history of insomnia since the age of 15.  The medical literature does not demonstrate that the brand name medication Ambien has superior efficacy as compared to the generic version, zolpidem.  The current medical evidence does not support the requested medication in this patients case.  Ambien is a benzodiazepine receptor agonist, and this class of medication is only intended for the short-term management of insomnia.  The documentation notes that the patient has been taking Ambien for many years.  All told, the requested brand name medication Ambien is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male has requested approval for weekly occupational therapy sessions for treatment of his attention deficit hyperactivity disorder.   Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). Few well designed studies examine the effectiveness of frequently used pediatric occupational therapy in well-defined, homogenous populations on outcomes that target participation in everyday life. A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. This patient has significant delays in fine motor and adaptive skills. Appropriate occupational therapy is medically necessary to help promote his adaptive skill development and independence (Wolraich and Bennett). All told, occupational therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested chemical dependency residential rehabilitation services for the treatment of his alcoholism. Findings:  The physician reviewer found that for this patient there was no need for inpatient treatment for detoxification. The patient had been on 2 mg of Ativan per day. This dosage represents a very nominal dosage from which he could well be detoxified on a diminishing regimen, purely on an outpatient basis. Therefore, there was no clinical justification for the residential treatment program, whether for Ativan or alcohol addiction. All told, there were no medical grounds to warrant the residential rehabilitation services at issue.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female has requested a positron emission tomography (PET) scan for evaluation of her stage 3 pancreatic cancer.   Findings:  Two physician reviewers found that the patient also reportedly has multiple sites of metastatic disease. She has been followed with imaging including positron emission tomography (PET) and computed tomography (CT) to evaluate her treatment status. The patients provider has recommended a PET/CT to assess need for treatment modification. The National Comprehensive Cancer Network (NCCN) guidelines reference an increased sensitivity for metastatic disease using PET versus CT or magnetic resonance imaging (MRI) alone. At the same time, the guidelines do not make a strong recommendation for using PET as a surveillance tool. Given the patients previous imaging and need for confirmation of disease status, the requested PET/CT has more sensitivity than conventional imaging and thus is likely to be more beneficial in this patients case.