Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for Afirma Gene Expression Classifier (CPT code 81545) for evaluation of the enrollees thyroid nodules.  Findings: Two physician reviewers found that based on the findings on the Afirma gene expression testing, nodule A was benign and no further testing was necessary. Nodule B was a follicular lesion of unknown significance but has high risk features of solid, hypoechoic and microcalcifications. Per the National Comprehensive Cancer Network (NCCN) guidelines, if a lesion has high risk features, thyroidectomy should be performed. While some data suggests that Afirma may ameliorate the need for surgery, high risk sonographic features support an indication for surgery (Chan, et al). Thus, the Afirma Gene Expression Classifier (CPT code 81545) was not likely to be more beneficial than standard available options including surgery for evaluation of this patients thyroid nodule.Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested radiofrequency ablation (RFA) for treatment of her Barretts esophagus (with low-grade dysplasia). Findings:  Two physician reviewers found that the use of RFA in this setting is not consistent with the standard of care in the community practice of gastroenterology. The relevant literature does not support the continued use of radiofrequency ablation in this setting.  While the literature suggests some utility for RFA in the treatment of Barretts esophagus, further studies are considered necessary in order to establish the effectiveness of this treatment in reducing cancer risk and in defining optimal management strategies versus surveillance. Fleischer and colleagues found that currently there is no treatment for dysplastic or non-dysplastic Barretts esophagus that achieves a complete response in all patients, eliminates all risk of developing cancer, results in zero adverse events or eliminates the need for surveillance. Thus, RFA has not been shown to have significant clinical advantage as compared to other options in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested for the medication Zyrtec (not the generic version) for treatment of her allergies. Findings:  The physician reviewer found that generic products can sometimes have intrasubject variability.  Thus, for some patients, the generic equivalent may not be as effective as the brand version.  In this patients case, she has allergy symptoms that were not relieved with cetirizine, which is the generic form of Zyrtec.  The patient reported that she currently uses eye drops, nasal drops and inhalers to help with her allergies. Per the patient, this combination with Zyrtec has helped with her symptoms.  The submitted documentation noted that the only allergy medication that has worked for this patient is Zyrtec in non-generic form.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 10-year-old female enrollee has requested  for electroencephalographic (EEG) biofeedback services for treatment of the enrollees behavioral health problems.   Findings:  Two physician reviewers found that there is a lack of peer-reviewed literature demonstrating superiority of EEG biofeedback over stimulant therapy. A trial comparing EEG biofeedback with stimulant medication using computerized tests of attention as the measure of efficacy concluded that biofeedback is of equal value in improving attention deficits (see Rossiter). However, there was no clear attempt to address this with cross-over maneuvers in this trial (i.e., switching therapeutic modalities between groups, placebo controls, etc.). This becomes problematic when considering an earlier smaller study that did include a cross-over placebo control (see Heywood and Beale) and identified significant confounds in the form of behavioral trends unrelated to training that may have been incorporated into the final analyses of improvement.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage rifaximin (Xifaxan). The records provided for review document that this patient has IBS-D and SIBO. The patients provider has recommended treatment with Xifaxan. As noted in the medical literature, Xifaxan has been demonstrated to be safe and effective for the treatment of IBS-D (Lembo, et al.). In addition, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. In the TARGET-3 trial of over 1,000 patients Xifaxan was reported to be effective with significant symptom improvement in patients with IBS-D (Lembo, et al.). Moreover, Xifaxan has proven highly effective in SIBO for eradication of bacteria and symptom relief (Scarpellini, et al.). Xifaxan showed greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and ciprofloxacin (Gatta and Scarpignato). For these reasons, the requested rifaximin (Xifaxan) is medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of her major depression.  Findings:  Two physicians found that while long-term data regarding the efficacy of VNS is not yet available, the submitted documentation demonstrates the patient has been refractory to all treatments for her depression. Though she has had adequate trials of more than four antidepressants, electroconvulsive therapy and various psychotherapeutic modalities, her depression is unrelenting and life threatening. In light of the severity of the patients illness and the lack of benefit with standard treatment, the use of VNS is this particular case is warranted.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested for radiofrequency ablation for treatment of his metastatic colon cancer.   Findings:  Two physician reviewers found that the primary role of RFA of hepatic lesions is to provide curative-intent therapy for those patients not amenable to surgical resection. As such, guidelines have limited the number and size of lesions to be treated. RFA is not considered to be a palliative intervention. In this patient, he is asymptomatic, and his CT suggests disease that cannot be ablated (both by the large size of the lesion, and the multiple lesions). While treatment options for his metastatic colon cancer are limited (i.e., clinical trials or re-treatment with chemotherapy), there is no evidence that RFA will provide any benefit (either palliative or curative).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement and authorization and coverage for Botulinum toxin (Botox) injections. The enrollee has diagnoses of gingival recession, limited range of motion, temporomandibular joint (TMJ) disorders, sleep-related bruxism, muscle spasm, atypical facial pain, myofascial pain, headache and dystonia. The enrollee has been treated for painful bruxism, which has been causing persistent facial pain, dystonia, and headaches. She has demonstrated improvement, indicating the treatments have been effective in alleviating pain due to bruxism. The enrollee notes she has nighttime teeth clenching, in addition to bruxism with no evidence she grinds her teeth. Most of the pain she has experienced from clenching her teeth, which is involuntary, occurs during the day. The enrollee maintains Botox injections are the only thing that has helped stop the teeth clenching and the pain it causes. Evidence-based review on the therapeutic usage of botulinum toxin (Botox) in non-cosmetic head and neck conditions indicates the need for more randomized controlled studies to confirm Botox is safe and reliable for routine clinical use in bruxism. Literature also describes the risk that administration of Botox into the lateral pterygoid muscles to treat TMJ disorders may bring about a fixed smile because of dissemination of the toxin into the superficial facial muscles. The current evidence regarding interventions for the management of bruxism is still inconclusive and does not support botulinum toxin therapy for any of the enrollees co-existing conditions associated with bruxism. A review of the use of botulinum toxin for myofascial pain syndrome (MPS) in adults shows more high-quality randomized controlled trials (RCTs) of botulinum toxin for treating MPS are needed before firm conclusions on its effectiveness and safety can be drawn. There is a lack of consensus on the therapeutic effects of botulinum toxin on TMJ disorders, whereby the medical necessity is not substantiated.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 oral and maxillofacial 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old female enrollee has requested botulinum toxin (Botox) 300 units for treatment of her migraine headaches.  Findings:  Three physician reviewers found that the available medical records provided for review indicate that the patient is being treated with 300 units of Botox for the reported condition of migraine headaches. However, there is a lack of documentation that the patient has been previously treated with Botox at the dosage of 155 units or of any specific objective outcome with standard Botox treatment. Botox is U.S. Food and Drug Administration (FDA) approved at 155 units for the prophylaxis of chronic migraine. Overall, the available medical records do not support the use of 300 units of Botox for the prophylaxis of migraine in the patient as likely to be more beneficial than standard Botox treatment with 155 units or less. Therefore, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

A 28-year-old male enrollee has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient sought emergency services for complaints of left eye redness, swelling and pain. He had a history of a chalazion for several months. Approximately a week prior to his visit to the emergency room, he developed increased swelling to the chalazion in his left eye. He applied warm compresses which he continued for one week with little improvement in his symptoms.  The patient left for a vacation and while away, the pain and swelling in his eyelid increased and there was a small amount of discharge. The patient sought medical attention at an emergency room. He had no fever and there was no loss of vision. The swelling was contained to his eyelid. The infection was drained and the patient was placed on antibiotic ophthalmic ointment.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention.  California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Chalazions are not acute medical emergencies. They are typically managed with warm compresses and antibiotic ointment with referral to an ophthalmologist when that fails.  In this case, the patient reports he experienced a significant worsening of pain and swelling and that his vision was blurry. The emergency physician record indicates that the patients pain in the emergency room was 2-3 out of 10 and his visual acuity was 20/20. The patient did not require narcotic analgesia. He received Motrin for pain. All told, the objective medical record documentation does not support the contention that the patient experienced a significant worsening of pain, swelling and vision problems at the time he sought emergency services. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health and thus would not have sought immediate medical attention for the patients complaints.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested for Neupogen (300mcg) injections for treatment of her neutropenia. Findings:  The physician reviewer found that recent guidelines from the American Association for the Study of Liver Diseases concluded that although there were currently insufficient data to recommend the routine use of G-CSF as a means of avoiding reductions in drug dosages, a number of small reports and anecdotal information from doctors treating co-infected individuals and post-transplant patients have suggested that the use of growth factors for neutropenia can be effective and generally well-tolerated. The current recommendation is use Neupogen when the ANC level drops to 750 or less to prevent any super-imposed infection during the course of HCV therapy, and to avoid any dose-reductions in hepatitis-C virus (HCV) therapy in an attempt to offer the patient the best chance to achieve sustained virological response (SVR) at the end of therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient has been diagnosed with chronic low back pain and right carpal tunnel syndrome. The patient was noted to have a history of a cerebrovascular accident without residual deficits. The patient reported back pain and occasional burning right leg pain. Right hand and right knee pain were also reported. He reported difficulty using his walker due to right hand pain. He also receives 16 hours per week of home care assistance. Physical examination findings included slow ambulation without focal neurological deficits. Tenderness was noted over the spine at multiple regions. Lumbar spine range of motion was reduced. In a letter, it was noted the patient was able to ambulate independently in his home with or without a walker. The patients fall risk was noted to be low. A heavy duty wheeled walker was recommended for aiding his mobility. The patient has requested authorization and coverage for a power wheelchair. The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a power wheelchair is medically necessary for the treatment of the patients medical condition. In this case, this patient was noted to ambulate slowly but independently. He was able to ambulate up to 100 feet with the assistance of a walker. There is no indication that the patient would be bed or chair confined without a power mobility device. The patient does not have cardiac, pulmonary, neurological, musculoskeletal or other pertinent organ system impairments that would preclude ambulation with a walker. Furthermore, the patient has multiple health conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device would encourage. Hagen and colleagues reported that the use of wheelchairs in place of physical exercise impairs bone and muscle health. The medical evidence does not support the requested device in this clinical setting. Therefore, a power wheelchair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 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: Medical Necessity
Decision: Upheld

The patient is a 22-year-old female with chronic pelvic pain who is requesting coverage for Actiq for pain control. The Health Plan has denied her request on the basis that Actiq is not medically indicated for treatment of chronic pelvic pain. At issue is whether Actiq is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no documentation provided indicating medical necessity for the use of the medication, Actiq. Actiq is currently approved for management of pain due to cancer related syndromes refractory to opioid treatment. It is not generally accepted in the utilization of chronic pelvic pain nor approved for such use. Furthermore, there are no peer-reviewed studies regarding the use of Actiq in the management of chronic pain unrelated to a malignant process. The patient has a significant pain syndrome, but there are other established medications available for non-cancer related breakthrough pain. Therefore, I have determined the requested medication is not medically necessary for treatment 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 Skyrizi 150 mg/mL pen. The records provided for review document that this patient presents with a two-year history of psoriasis with a BSA of 5% and disease involvement on the genitals and scalp. The patient has been treated with and failed to substantially improve with two IL-17 pathway inhibitors including ixekizumab and secukinumab. The patients provider has recommended treatment with Skyrizi. The systemic treatment of psoriasis is indicated when topical treatments are not tolerated or fail to achieve sufficient control of disease. Systemic therapies are particularly important to control psoriasis on the scalp, hands, and other areas that are difficult to treat with topical medications. There are several systemic options for the treatment of patients with psoriasis including non-biologics and biologics. Data suggests that biologics such as Skyrizi, which is an IL-23 inhibitor, have greater demonstrated efficacy when compared to non-biologic therapies (Armstrong, et al.; Menter, et al.). Given this patients failure of IL-17 agents, treatment with a less efficacious agent such as a tumor necrosis factor (TNF)-alpha inhibitor is not recommended. The medical literature and guidelines support treatment with an IL-23 inhibitor such as Skyrizi for treatment of this patients psoriasis. For these reasons, the requested Skyrizi 150 mg/mL pen is medically necessary for 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for discectomy at vertebrae L5-S1. The records document that this patients complaints include back pain with intermittent radicular pain every two to three years. Review of a magnetic resonance imaging (MRI) study showed some lateral recess stenosis. However, the MRI did not reveal any evidence of severe stenosis or a significant herniated disc to justify discectomy surgery (Motiei-Langroudi, et al.). In addition, the patient has an elevated hemoglobin A1C, which is a contraindication for spine surgery. Hikata and colleagues noted that diabetes mellitus is a risk factor for surgical site infection (SSI), which is a serious complication after spinal surgery. The authors suggest lowering a patients hemoglobin A1C to under 7% before considering surgical intervention. This patients provider has advised continued treatment with conservative care, which is consistent with the recommendations in the medical literature. Given lack of herniated disc on MRI and the patients highly elevated hemoglobin A1C, the requested discectomy at vertebrae L5-S1 is not medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG). Human herpesvirus 6 (HHV6) can cause illness or acute rejection in patients with a liver transplant. Multiple therapies, including Valcyte, cidofovir, and foscarnet have shown efficacy in treatment. However, there is a lack of high-quality medical literature to support the use of IVIG as safe and effective for the treatment of HHV6 in immunosuppressed patients with a liver transplant. Overall, there is a lack of medical studies to support the use of IVIG. In addition, the records do not document that the patient has exhausted the current standard of care for HHV6. All told, IVIG is not medically necessary for the 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested for speech therapy for treatment of his speech disorder subsequent to head trauma. Findings:  The physician reviewer found that complex concussions involve cognitive impairment, such as poor attention or concentration, memory dysfunction, irritability, anxiety, depressed mood, sleep disturbance, persistent low-grade headache, lightheadedness, and sensitivity to light or sound. The term post-concussive syndrome/disorder has been used to describe these prolonged symptoms and cognitive impairment. This patient has a history of multiple episodes of blunt head trauma, at least two of which were associated with LOC.