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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation.Findings:  Two of the three physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the services at issue. The therapy for overactive bladder includes behavior modification, pelvic floor therapy, anticholinergics, antimuscarinics/beta blockers, biofeedback, percutaneous tibial nerve stimulation, Botox and sacral modulators. In this patients case, the records noted that the medications Detrol and Myrbetriq were tried. The records did not document that the patient failed a trial of Vesicare. The medical evidence has not established an additional benefit of percutaneous tibial nerve stimulation over Vesicare. Percutaneous tibial nerve stimulation is likely to have the same efficacy as Vesicare over the short-term. Therefore, percutaneous tibial nerve stimulation was not and is not likely to be more effective than other treatment options.Final Result: The reviewers determined that the services at issue were not and are 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: Physician reviewers 1, 2 and 3 are board certified in urology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for lumbar spinal fusion, related services and hospital stay. Decompression surgery for lumbar spinal stenosis is the most common spinal procedure in the elderly. In the presence of multilevel severe spinal stenosis with evidence of neural compression, as in this case, decompression is known to be of benefit. Per the records, the patients spinal stenosis was severe and involved multiple levels. There was clinical evidence of neurogenic claudication. Based on the severity of the pain and the severe spinal stenosis on the MRI scan, additional conservative treatment was not likely to have been beneficial. The weakness of the legs necessitated surgical decompression on an urgent basis. The medical evidence suggests that decompression plus fusion may be better than decompression alone in the treatment of multilevel advanced degenerative changes resulting in degenerative spondylolisthesis. Fusion has advantages of reduction of postoperative leg pain, with similar complication rate to decompression alone. All told, lumbar spinal fusion, related services and hospital stay were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee, with worsening anxiety, has requested authorization for psychiatric residential treatment services. Findings:  The physician reviewer found that the range of psychotherapies offered could have been provided via another level of care such as partial hospitalization. The patient was able to avail herself of psychotherapy, and though she was rather wary of medical treatment, pharmacologic agents could have been provided on an outpatient basis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 2. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret for eight weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 enrollees parent has requested reimbursement and prospective authorization and coverage for food tolerance induction program services (CPT 95044 and 95018) and 22 future dates of services. Oral immunotherapy has not been recommended as a standard care for treatment of food allergies by the American Academy of Allergy Asthma and Immunology (AAAAI) guidelines due to uncertainty whether therapeutic benefit outweighs risk of treatment. Although some studies have reported potential benefits, according to the AAAAI, the safety and efficacy of oral immunotherapy has not been established as superior to allergen avoidance. Furthermore, oral immunotherapy is associated with a higher rate of systemic adverse events compared with other forms of immunotherapy as well as a minor risk of eosinophilic esophagitis. Oral immunotherapy has not been recommended as a standard of care to provide for patients with food allergies (Nowak-Wegryzn, et al.). For this patients food allergies, the standard of care remains food avoidance and availability of an epinephrine autoinjector. Given these findings, the food tolerance induction program services (CPT 95044 and 95018) and 22 future dates of services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the food tolerance induction program services (CPT 95044 and 95018) and 22 future dates of services were not and are 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 services at issue were not and are 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: Physician reviewer 1 is board certified in allergy and  immunology with subspecialty certification in pediatrics and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and  immunology and is 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: Overturned

A 46-year-old female enrollee requested genetic testing for medical evaluation of her thyroid nodule.  Findings:  Three physician reviewers found that thyroid nodules are commonly managed by diagnostic fine needle aspiration to evaluate the cytopathology. In this case, the finding by this standard technique was atypia of undetermined significance. This patient was facing total thyroidectomy if malignancy was present, and only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted for gene expression analysis. The overall conclusions by both Alexander and colleagues and Chudova and colleagues are that unnecessary thyroid surgeries may be prevented by implementation of the gene expression test. Based on the peer-reviewed literature cited above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Overturned

A parent of a nine-year-old male enrollee has requested  emergency services for treatment of the enrollee's headache.  Findings:  The physician reviewer found that review of the submitted documentation indicates that the patient was seen in the emergency department for the recurrence of a headache that had been occurring episodically for a five-month period. On the date in question, the headache suffered by the patient was of sufficient severity such that absence of immediate medical attention could reasonably be expected to result in placing the patients health in jeopardy due to continued pain and suffering and possible progression of a potentially serious neurologic disorder. As noted by the parent, the patient had not responded to the medication administered at home and was in severe pain and appeared to be near syncope. Thus, the decision to seek immediate medical attention in an emergency department was appropriate.
Appeal type: Urgent Care
Decision: Upheld

A 52-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. 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. This patient presented to the emergency room with a two-day history of fever, cough, sore throat and body aches. Although he had some shortness of breath, he was ambulatory upon presentation. The records reflect that he was in no apparent distress. The patient was febrile, but other vital signs were normal. The only laboratory data ordered was a strep screen. The patient did not require blood tests, a chest x-ray, or any intravenous fluids or medications in the emergency room. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms were not severe or sudden in onset. A prudent layperson in the patients circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a transcutaneous electrical nerve stimulation (TENS) device and electrodes for treatment of the enrollees low back pain with radiation to right anterior thigh. Findings:  The physician reviewer found that while TENS may reflect the longstanding accepted standard of care within many medical communities, the results of clinical trials are inconclusive regarding improved health outcomes. Overall, the published studies do not provide information on the stimulation parameters which are most likely to provide optimum pain relief, nor do they answer questions about long-term effectiveness. Several published evidence based assessments of TENS have found that evidence is lacking concerning effectiveness. Many studies only evaluated single-dose treatment, while other problems included statistical methodology, small sample size, influence of placebo effect, and difficulty comparing the different outcomes that were measured. One study reported that the treatment of neuropathic pain is largely empirical, often relying heavily on data from small, generally poorly-designed clinical trials or anecdotal. They reported an indication of TENS for phantom limb pain. In addition, another study found that TENS may be a supplement to medical treatment in the management of spasticity in spinal cord injury. Further, more research supported use of TENS in treating multiple sclerosis in patients with pain and muscle spasm. However, TENS is not recommended for use in treating chronic low back pain. Upon review of the submitted documentation, the requested TENS device and electrodes are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 47-year-old female enrollee has requested prolotherapy treatments for treatment of her chronic low back pain, left greater than right, and sacroiliac joint arthropathy.  Findings:  Three physician reviewers found that prolotherapy was not and is not likely to be the most beneficial treatment for this patients chronic low back pain and sacroiliac joint arthropathy.  There is insufficient evidence in the literature to support the efficacy of prolotherapy for the treatment of the patients chronic medical condition. Additionally, there are alternative therapies which are supported by the medical literature which may be effective in treating the patients chronic pain condition.Yelland and colleagues published a randomized control trial on prolotherapy injections, saline injections, and exercise for chronic low back pain. The objective was to assess the efficacy of prolotherapy injections and exercise protocol in the treatment of chronic nonspecific low back pain. The  hypothesis concluded that prolotherapy injections and exercise was no more effective than the control treatment.  Dagenais and colleagues conducted a critical review of the literature on prolotherapy for spinal pain. The review found that most clinical studies reported positive results, such as decreased pain or disability. Differences, however, between treatment and control groups did not always reach statistical significance. They concluded that there were great variations in the injection and treatment protocols for prolotherapy that preclude definite conclusions. They further asserted that future research should focus on those solutions and protocols that are most commonly used in trials reporting effectiveness to help determine which patients, if any, are most likely to benefit from this treatment.  All told, the superior efficacy of the services at issue has not been established at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a lymphoscintigraphy with single photon emission computed tomography/computed tomography (SPECT/CT) for evaluation of the enrollees melanoma. Findings: Three physician reviewers found that Lymphoscintigraphy in patients with melanoma is recognized as a valuable diagnostic procedure in pre-operative localization of the sentinel node. The addition of SPECT with CT imaging is of value over planar imaging with improved spatial and contrast resolution with a more detailed and accurate mapping of regional draining and sentinel nodes. Resection and biopsy of these nodes has been proven to have an impact on patient survival. For this reason, the addition of SPECT/CT was more advantageous to the patient than had the exam been done with planar imaging alone. Thus, the lymphoscintigraphy with SPECT/CT was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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

The patient is a 52-year-old female with a history of chemical hepatitis, severe persistent asthma and breast cancer. According to a letter dated December 2005, the patient was on Advair 500, Zyrtec-D, Singulair, albuterol MDI and albuterol via nebulizer.The patients pulmonologist indicates he has requested Xolair since September 2004. The patient had 20 unscheduled office visits in the past year. The pulmonologist did not want to keep the patient on high dose inhaled corticosteroids because she gets oral thrush. The IgE level was 465. Pulmonary function tests performed in September 2005 showed normal flow rates with an FEV1 of 117% of predicted. The pulmonologist states that the normal PFT is only a snapshot of the patients lung function. There were no records of flow-volume loops during the patients office visits.The Health Plan has denied use of Xolair on the basis that the patient did not meet the necessary inclusion criteria, specifically, a normal FEV1 and inconsistent use of controller medications based on pharmacy records.The purpose of this review is to determine if Xolair is medically necessary for treatment of the patients medical condition.Xolair is indicated in patients with moderate to severe asthma and positive skin test reactivity to aeroallergens. The initial study has patients with FEV1 between 40-80% of predicted, a change of FEV1 of more than 12% after bronchodilators, total IgE between 30-700 IU and a body weight of less than 150 kg. If a patient has an FEV1 greater than 80%, he or she must be on oral prednisone of a dose of 5 mg or more.According to the submitted records the patients FEV1 was 117% of predicted. The records do not indicate that the patient was placed on oral corticosteroids despite multiple episodes of exacerbations. The pulmonologist states he did not want to use oral corticosteroids because of its systemic side effects. While there is an appreciable need to minimize the use of systemic corticosteroids because of the long-term adverse effects, the records do not indicate even intermittent use by this patient. If the patient has experienced many exacerbations, the inflammatory changes can result in lung remodeling and worsening lung functions. Because of the normal pulmonary function tests, alternative diagnoses such as vocal cord dysfunction should be considered. In addition, a trial of oral prednisone would be appropriate. Significant improvement on prednisone would be a better predictor of whether or not Xolair will be effective. However, at this time there is insufficient evidence that the use of Xolair is medically indicated or necessary for this patient.As set forth above, 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: An enrollee has requested facial laser hair removal for treatment of her gender dysphoria.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient has been diagnosed with gender dysphoria. Given the patients diagnosis, services that help ameliorate the patients male features can be considered medically necessary. In this patients case, the presence of male facial hair is contributing to the patients gender dysphoria. Thus, facial laser hair removal is medically necessary for treatment of her medical condition. Further, facial laser hair removal is considered reconstructive in this setting. The presence of facial hair in a female would be considered abnormal and is referred to as hirsutism. The `abnormal` hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. The requested laser hair removal will create a more normal feminine facial appearance. The requested laser hair removal can provide substantial improvement in the appearance of the patients terminal hair. As such, the requested service is considered reconstructive in this clinical setting.  Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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.