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

The parent of a three-year-old male has requested speech and occupational therapy services for treatment of his autistic disorder. Findings:  The physician reviewer found that occupational therapy studies have shown benefits that prevent deterioration or a reversal of function and result in a significant improvement in activities of daily living (Case-Smith & Arbesman; and Shoener). In addition, occupational therapy combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development. The medical community has also determined that occupational and speech therapies are medically necessary as evidenced by the American Academy of Neurology guidelines for autism which state that the immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. Individuals with mild autism should also receive adequate assessments and appropriate diagnoses and therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male enrollee has requested intensive outpatient cognitive therapy for the treatment of his behavioral health problems. Findings:  The physician reviewer found that this patient had continued symptomatology associated with his diagnosis of major depression with an increase in anxiety and depressive symptoms as well as recent family stressors. Continued participation in the intensive outpatient cognitive therapy program was medically indicated for this patient and was consistent with American Psychiatric Association practice guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested for Avastin therapy for treatment of his colon cancer metastatic to liver.   Findings:  Two physician reviewers found that there is no data to suggest that the continued use of this current regimen, in whole or in part, is of any clinical benefit. All one could expect from such an approach would be continued risk of toxicity and no benefit. Accordingly, the continued use of Avastin in this situation is, at best, investigational, and of no known clinical benefit.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for phentermine HCL (37.5 mg tablets, taken once daily). Obesity can lead to numerous complications including type 2 diabetes, hypertension, and cardiovascular disease (Gadde, et al.). This patients records document the presence of obesity as well as multiple comorbidities including type 2 diabetes, hypertension, and dyslipidemia. Son and Kim noted that, As it is difficult to achieve and sustain successful long-term weight loss in most patients with obesity through lifestyle modifications (e.g., diet, exercise, and behavioral therapy), pharmacological approaches to the treatment of obesity should be considered as an adjunct therapy. The U.S. Food and Drug Administration (FDA) has approved phentermine for weight management as an adjunct to caloric restriction and lifestyle modifications for obese and overweight patients with weight-related comorbidities (Narayanaswami and Dwoskin). This patient has reportedly responded well to treatment with phentermine in the past. Given these findings, the requested phentermine HCL (37.5 mg tablets, taken once daily) 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi, Daklinza and ribavirin for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive, genotype 3 patients, therapy is recommended with Sovaldi and Daklinza with ribavirin for 12 weeks.  Per the guidelines, only interferon-eligible patients can be treated with Sovaldi, peg-interferon, and ribavirin.  This patient is interferon-ineligible due to a pre-existing medical condition.  For these reasons, the requested treatment with Sovaldi, Daklinza, and ribavirin is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization for radiofrequency neurolysis of the occipital nerve for treatment of the enrollees occipital neuralgia. Findings:  All three physician reviewers found that the patient has a history of occipital neuralgia, cochlear implant, spondylosis, degenerative disc disease, lumbar radiculopathy and post-laminectomy syndrome. The patient presented with chronic severe head, face and ear pain with ongoing low back pain. The patient has tried treatment with medication, massage, epidural injections and stem cell injections at L5 and S1 and stromal vascular fraction (SVF). The provider recommends radiofrequency lesioning of the occipital nerve. The patient has requested authorization and coverage for radiofrequency neurolysis of the occipital nerve.  One study reported that occipital nerve radiofrequency has not demonstrated long-term benefit for treatment of neuralgia. In addition, another study reported that occipital nerve radiofrequency is not supported as there is a lack of demonstrated long-term benefit from the therapy. Moreover, there is insufficient published peer-reviewed controlled studies regarding radiofrequency of the occipital nerve to support the treatment. In this case, the documentation submitted for review do not support the requested procedure. The records do not show a contraindication to current conservative care to support radiofrequency of the occipital nerve.  Final Result: All three reviewers determined that the requested service is not likely to be more beneficial for treatment 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 neurology with sub-specialty certification in pain medicine and are 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility services for the treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Functional impairments due to acquired brain insults such as stroke can improve with time, but are also amenable to rehabilitation interventions.  The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature.  In this patients case, she sustained ischemic stroke.  She underwent extensive inpatient rehabilitation at the acute inpatient rehabilitation level, as well as the skilled nursing facility level of care.  She made significant functional progress.  As of the date in question, she had progressed to ambulating household distances with a cane at the contact guard assistance level.  Further reconditioning and ongoing rehabilitative management could have been provided at the home and outpatient settings.  The records do not document any issues that would indicate that the patients rehabilitative needs could not have been safely provided at a lower level of care in the home with supervision to custodial level assistance and community-based rehabilitative services.  There are no documented ongoing skilled nursing needs requiring ongoing inpatient care in the available records.  All told, the skilled nursing facility services at issue were not and are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Klonopin 1 mg three times per day for treatment of the enrollees anxiety. Findings:  The physician reviewer found that in the documentation available for review, the patient has seen multiple providers and they all agree that benzodiazepine use is not indicated in this patients medical condition. The patients records document self-medicating as he feels appropriate. Benzodiazepine abuse has clear hazards. The patients providers have recommended treatment without the use of controlled substance medications, consistent with current recommendations. Any future care in regards to any controlled substance medication should only be under the direct guidance of a mental health professional. For these reasons, the requested Klonopin 1 mg three times per day is not medically necessary for treatment of the 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old male enrollee has requested for a consultation with a specialist for occipital nerve decompression for treatment of his neuralgia. Findings:  Three physician reviewers found that this patient has chronic neck pain and numbness of his face and right upper extremity with a normal examination and normal MRI. The diagnoses of occipital neuralgia, migraine, and cervicogenic headache have not been proven. There is a lack of large, prospective, scientific, randomized studies proving the efficacy of surgical treatment of occipital neuralgia.  There is also a lack of any large, randomized studies showing its long-term effectiveness. The above cited studies have described retrospective, small number, non-randomized series reporting short-term effectiveness of surgical treatment. In this patients case, the requested services are not likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Euflexxa injections for treatment of her osteoarthritis. Findings: The physician reviewer found that the evidence based medical guidelines and peer-reviewed literature does not support the use of hyaluronic acid injections, such as Euflexxa, for osteoarthritis in the knees. Its use for treatment of osteoarthritis of the knee remains the subject of debate because the use of hyaluronan is not consistently supported by evidence based literature. The rationale for the use of hyaluronan includes the concept that proinflammatory mediators and metalloproteinases (MMPs) that stimulate chondrocytes to syntheses endogenous hyaluronic acid and proteoglycans will be affected positively by the injection of hyaluronic acid. There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection in a number of joints including the knee joint and the hip joint. A recent meta-analysis of the efficacy of viscosupplementation has been performed. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Rutjes, et al). The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines state the following regarding the use of hyaluronic acid, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. A meta-analysis by Lo and colleagues concluded that intraarticular hyaluronic acid has a small effect when compared to intraarticular placebo and that publication bias suggests that this effect may be overestimated. Moreover, the medical literature also discusses possibilities of complications, such as iatrogenic intraarticular infection and negative effects of lidocaine or Marcaine intraarticular and sensitivity reactions. The incidents of sensitivity reactions are likely to increase following repeated exposures such as has occurred for this patient in her multiple injections series. In summary, given the weak literature support as well as the possibility of complications with repeated injections, there is inadequate evidence to warrant the use of hyaluronan, in the form of Euflexxa in this case. For these reasons, the requested injections are not medically necessary for treatment and management of this patients medical condition.  Final Result: The reviewer determined that the requested injections are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested bilateral hip resurfacing (using Conserve Plus) for the treatment of his bilateral hip osteoarthritis. Findings:  The physician reviewer found that the requested hip resurfacing procedure using Conserve Plus is currently not FDA-approved. The differences between Conserve Plus and the 2 approved hip resurfacing implants (Birmingham and Cormet implants) are minimal and their track records are comparable. However, given the patients advanced age, his condition is more appropriately treated with a traditional large metal-on-metal type implant than hip resurfacing with the Conserve Plus.
Appeal type: Experimental/Investigational
Decision: Upheld

A sixty-three year-old male with severe stenosis at L4-5 and spondylolisthesis and disc protrusion at L5-S1 is requesting coverage for an X-Stop decompression procedure.Reviewers Findings:One of the three reviewing physicians found that the patient has long-standing pain and has attempted conservative treatment.  The procedure is medically reasonable for the patient in an attempt to alleviate pain.  This reviewer found that the Health Plan denial should be overturned.Two of the reviewing physicians found that the X-Stop does not have long-term outcome studies to justify its use in patients with stenosis with spondylolisthesis.  Therefore, this procedure would not be more beneficial for treatment of the patients medical condition.  These two physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for OxyContin 12-hour extended release 20 mg, two times daily. The Centers for Disease Control and Prevention guidelines state that non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The 2017 Federation of State Medical Boards guidelines for the chronic use of opioid analgesics recommends, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. The guidelines recommend that providers, maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic pain involving the cervical spine and lumbar spine. She has had severe headaches related to hydrocephalus affecting her activities of daily living. She has attempted several forms of conservative non-opioid therapy, with marginal results. She is not a candidate for further surgery and spinal injections according to her provider. She has been on chronic opioid therapy for several years, and she has tried and failed several medications. Her urine toxicology screening and CURES reports have been consistent with therapy. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested OxyContin 12-hour extended release 20 mg, two times daily is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sublocade (300 mg injection once a month). At issue is whether Sublocade (300 mg injection once a month) is medically necessary to treat the enrollees mental health or substance use disorder medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.The submitted documentation does not support the medical necessity of the requested medication. Strain and colleagues report that medication-assisted treatment (MAT), consisting of treatment with an opioid agonist or antagonist and adjunctive psychosocial treatment, is first-line treatment for most patients with an opioid use disorder. Buprenorphine is available in daily transmucosal formulations, as a long-acting six-month implant, and as an extended-release subcutaneous injection. The aim of therapy with long-acting injectable buprenorphine is to address problems with limited adherence, diversion, and misuse of the transmucosal formulation. In this case, the patient declined referral to a methadone clinic for continued treatment of opioid addiction. Given that the records do not document that this patient has failed sublingual Suboxone therapy due to nonadherence, diversion, or misuse, the requested medication is not medically indicated. Sublocade (300 mg injection once a month) is not in accordance with the generally accepted standards of mental health and substance use disorder care. Sublocade (300 mg injection once a month) is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, Sublocade (300 mg injection once a month) 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 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.