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

An enrollee has requested reimbursement for laparoscopic surgical ablation with imaging guidance. For this patient, radiofrequency ablation allowed the provider to directly visualize and target the one large fibroid. This method is minimally invasive to decrease risks and allows for a quick recovery. Although there is limited long-term data demonstrating superior health outcomes with radiofrequency ablation, data from recent studies have reported excellent results. Researchers found that 94% of the patients in their study reported satisfaction at 12 months. The authors concluded that the procedure is well tolerated and provides symptom relief and short recovery time. Given these findings, the laparoscopic surgical ablation with imaging guidance was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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

A 29-year-old female enrollee has requested continued inpatient stay at an acute level of care for the treatment of her uncontrolled diabetes. Findings:  The physician reviewer found that the patient was admitted for uncontrolled Type 1 diabetes, as well as persistent nausea and vomiting. She has demonstrated extremely serious non-compliance. For the immediate future, it is critical for this patient, for both maternal and fetal indications, to remain as an inpatient until she is under strict glucose control. Her obstetricians must also give extremely serious consideration to the management of her pregnancy for the duration. She is now approaching fetal viability. They have appropriately considered the increased risk of intrauterine fetal demise in this situation and want to reduce that risk as much as possible. The patient has clearly demonstrated that she has not and will not remain compliant with her care. This places her at great risk for maternal and fetal morbidity and mortality. Her obstetricians have appropriately recommended inpatient care until delivery, and as an alternative considered home health care for consistent insulin dosing and glucose control. Given the patients ambivalence concerning her condition, and refusal to accept home health care, it would be below the standard of care for her obstetricians to allow her to be discharged. Inpatient care is essential to meet the standard of care in the case of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female has requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that the patient's provider reported that the patient has been resistant to treatment with multiple trials of psychopharmacologic agents, including Emsam patch, Elavil, Cymbalta, Lexapro, Prozac, Effexor, Remeron, Zoloft, Abilify, nortriptyline, Luvox, Desyrel, Celexa, imipramine, Paxil, Wellbutrin, and Pristiq.  The patient reported thoughts of suicide, anhedonia, cognitive impairment, interpersonal withdrawal, difficulty sleeping, suicidal ideation, irritability, fatigue, and weight changes.  The provider noted that the patient had electroconvulsive therapy in the past, with no response.  In this patients case, the requested services are likely to be of greater benefit than other available treatment alternatives.  The American Psychiatric Association has noted that transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not respond to medication therapy.  This patient has already undergone 25 sessions of electroconvulsive therapy, with no response.  Her prior medications have included combinations of antidepressants, mood stabilizers, and anti-anxiety medications.  Psychotherapy and cognitive therapy have also been provided.  The patient continues to be symptomatic.  In this clinical setting, transcranial magnetic stimulation is likely to be more beneficial than other treatment modalities.  All told, the requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) is likely to be superior over other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma gene test.  Findings:  Three physician reviewers found that in this case, the cytopathology was consistent with AUS, and the specimen was sent for genetic testing, which was consistent with a benign finding. The Bethesda System recommends a second fine needle aspiration (FNA) when the cytopathology is consistent with AUS (Cibas, et al). The American Thyroid Association guidelines state that for nodules with [atypia of unknown significance/follicular lesion of undetermined significance] (AUS/FLUS) cytology after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making.  The median risk of malignancy on AUS lesions is 15%. According to the Bethesda system and the American Thyroid Association guidelines a second biopsy is recommended. However, molecular testing may be used as an alternative. If the genetic test is suspicious the risk of malignancy increases to 40%. However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing. Thus, the testing at issue is beneficial for the medical decision making. Proceeding directly to the genetic testing prevented a second biopsy procedure. The benign finding would allow the patient and provider to make an informed decision on whether to continue surveillance or proceed to surgery. In this clinical setting proceeding with genetic testing was the best management option for this patient and was appropriate with current standard of care. Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested for continued treatment with Sporanox (itraconazole) for treatment of his sinusitis.  Findings:  The physician reviewer found that it is believed that some cases of chronic rhinosinusitis may be the result of nasal colonization with fungi combined with an allergic reaction to fungal antigens. It is not clear how often this occurs, but it is a bona fide cause of at least some cases of this condition. A review of the literature identified instances where treatment with antifungals has essentially cured chronic sinusitis. An additional study (Rains & Minick) reported on some 139 patients with allergic fungal rhinosinusitis. The study abstract indicates there were no adverse reactions to the 36,000 doses of itraconazole given to the study participants.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a second opinion consultation with an out-of-network ophthalmologist for the evaluation of her condition. Findings:  The physician reviewer found that the optometrist noted best corrected vision of 20/25 and 20/40. He noted ocular pressure of 26 and mild cataracts in each eye. The optometrist did not describe damage to the optic nerve but did say there was early disruption of the left macula. On another visit, the provider noted vision of 20/20 and 20/40 and pressures of 22 and 21. The drawings of the optic nerve were normal, and no mention was made of cataracts or macular degeneration. Visual fields and optical coherence tomography scanning were ordered. The patient did not keep the appointment for these tests. These ordered tests are certainly recommended, as is a second opinion. However, as there are several qualified providers on the staff, an out-of-network referral is not medically warranted.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female has requested a second ablation therapy for treatment of her low back pain.  Findings:  Two physician reviewers found that the patient has chronic low back pain. Seven months ago, lumbar medial branch nerve blocks on the left and right at L4, L5, and S1 were performed.  She reported six hours of complete pain relief following the diagnostic lumbar medial branch nerve blocks.  One month later, radiofrequency lumbar medial branch neurotomy bilaterally at L4, L5, and S1 were performed.  The following month, the patient reported recurrent left buttock pain.  In this clinical setting, the requested services are not likely to be more beneficial than other treatment options.  This patient has chronic low back pain which has failed to respond to multiple modalities of treatments.  However, the submitted documentation does not support the requested services in this patients case.  High volumes of solutions were utilized during the lumbar medial branch nerve blocks, thus compromising the diagnostic specificity.  Diagnostic blocks must be performed utilizing appropriate methodology with low volume injections.  In general, there should be six months of relief prior to a second radiofrequency neurotomy.  In sum, a second ablation therapy is not likely to be more effective than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested a clinical trial and the associated tests/services including PET scan, CT scan, blood tests and a CTC for the treatment of her breast cancer. Findings:  Three physician reviewers found that high-dose chemotherapy and autologous stem cell transplant has not been shown, in randomized trials, to offer any survival advantage to women with metastatic breast cancer. As such, this treatment is considered investigational, at best, and of no proven benefit nor medical necessity. Any follow-up tests required by participation in the clinical trial (above and beyond what might be considered routine tests for the follow-up of metastatic breast cancer) are likewise to be considered investigational.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for solifenacin succinate 10 mg.Oxybutynin and solifenacin succinate are both oral antimuscarinics or anticholinergics and are used to treat overactive bladder. According to the American Urological Association (AUA), if a patient experiences unacceptable adverse drug events with one antimuscarinic medication, then a different antimuscarinic medication may be tried. In this case, the patient has tried and failed oxybutynin. The patient had dry mouth that made the medication intolerable. Therefore, solifenacin succinate 10 mg is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to himself or others. He had no self-harm urges.  He was medically stable.  He was no longer psychotic and he was not manic.  Although still depressed, this appeared to be at his baseline level.  There were no emotional, behavioral, cognitive or impulsive issues preventing him from continuing treatment at outpatient level of care. He was attending to his activities of daily living appropriately.  He had stable housing and family support.   He was actively involved in his treatment and future oriented. There was no evidence to suggest that continuing his treatment at a lower level of care would have led to decompensation.  His medication management could have been administered on an outpatient basis. The patient could have continued medication management, cognitive therapy, group therapy, and meetings in an outpatient program. The patient no longer required treatment at three days per week, multiple hours per day at IOP level of care.  In sum, the services at issue forward were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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: Urgent Care
Decision: Overturned

A 63-year-old female enrollee has requested services on an emergent basis. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date of service at issue. 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. Review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the principal determinate of the need to seek evaluation in an emergency department was the degree of pain that the patient was in. The fact that she had a pain level of 8 out of 10, constitutes grounds for a prudent layperson to have thought this to be an emergency medical condition and to have sought immediate medical attention in an emergency department. The patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested right total ankle replacement surgery for the treatment of her right ankle pain. Findings:  Three physician reviewers found that total ankle arthroplasty is an accepted medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis (fusion) remains the subject of debate. For arthritic conditions regarding the ankle, there are a number of peer-reviewed articles comparing fusion with ankle replacement in the short- and intermediate-term, and both procedures have good results. The patients provider has recommended total ankle arthroplasty over fusion due to concern that the patient is at risk of developing arthritis in other joints, which can occur with fusion. This rationale is medically prudent and sound. The procedure chosen by the patients provider is likely to produce the best outcome for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 15-year-old female enrollee has requested  zone 1 evaluation of autologous hematopoietic stem cell transplant and stem cell harvest and storage for treatment of the enrollees osteosarcoma. Findings:  Two physician reviewers found that the patient has apparent progressive disease despite frontline chemotherapy. Given the location of the lesions, she cannot undergo surgery for local control. There is data demonstrating that high-dose samarium has shown response in osteosarcoma patients in terms of symptom improvement. A study showed overall palliation of pain was impressive, with patients eventually requiring either less opiate medication or being able to discontinue opiates (Anderson, et al.(2002). Another study of high-dose samarium plus gemcitabine showed that of the 12 patients followed after one year, there were no durable responses to treatment (Anderson, et al., 2005). The authors stated, although high-dose samarium plus gemcitabine has moderate palliative activity (improved pain; radiologic responses) in this poor-risk population, additional measures of local and systemic control are required for durable control of relapsed osteosarcoma with osteoblastic lesions. Thus, while high-dose samarium has shown some efficacy for palliation, it has not been shown to improve overall survival. At this time, there is a lack of phase III trial data to support samarium as a curative measure in the setting.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services. Group A streptococcus (GAS) is a very common cause of pharyngitis in school-aged children. It classically presents with rapid onset of sore throat and fever. The tonsils are frequently red and swollen, with a gray or white exudate. There may be associated anterior cervical lymphadenopathy, headache, abdominal pain, nausea, and vomiting. When rash is present, it is given the name scarlatina, occurring as a result of toxin production one to two days after onset of illness. Scarlet fever combines upper respiratory tract infections symptoms with a characteristic rash produced by infection with pyrogenic exotoxin-producing GAS. The rash typically appears one to two days after onset of symptoms, and is described as diffuse, finely popular, and erythematous, producing a bright red discoloration that blanches with pressure. After about four days, it fades and the skin desquamates. The tongue also has a characteristic appearance with white coating and swollen erythematous papillae. Cough, conjunctivitis, and diarrhea are more suggestive of a viral etiology. Rapid strep testing is very specific, but not very sensitive. Throat culture is the gold standard. Therapy includes symptomatic treatment as well as antibiotic therapy if GAS is highly suspected. Complications of GAS pharyngitis include parapharyngeal abscess, acute post-streptococcal glomerulonephritis, post-streptococcal reactive arthritis, and possibly several neuropsychiatric disorders. In this patients case, she was taken to urgent care with fever, sore throat, and cough. She was not clinically dehydrated. She was hemodynamically stable, and she was in no respiratory distress. Her examination was significant for erythematous and swollen tonsils and associated anterior cervical lymphadenopathy. Her situation was not an emergency, and the care that she received was comparable to care provided in a primary care office. Therefore, the services at issue were not emergency medical services. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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

A 52-year-old male enrollee has requested for Marinol for treatment of her chronic pain. Findings:  The physician reviewer found that the peer reviewed medical literature demonstrates that there is greater scientific support for the use of standard  medications for patients with chronic pain than there is for the use of Marinol.. In sum, there is a paucity of research indicating the efficacy of Marinol in the treatment of this patients condition. As such, the medical necessity of Marinol for this patient has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested a dual isotope stress test/stress echocardiogram for an evaluation of his medical condition. Findings:  The physician reviewer found that stress myocardial perfusion imaging provides reliable prognostic information. This particular patient had several cardiac risk factors and a high pre-test calcium score for which the dual isotope stress test/stress echocardiogram was clinically indicated.  The results of the nuclear stress were important to the patients clinical treatment plan.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested Botox injections for treatment of her migraine headache. Findings:  The physician reviewer found that this patient has been diagnosed with migraine, with medication overuse. There is no evidence that she has tried standard preventives in the past, or that detox from daily analgesics has been tried. Nor is there evidence that acute migraine abortive agents such as triptans have been used. Phase 3 studies of Botox for treatment of individuals with chronic migraine have shown clinical and statistical benefit in reduction of headache days in comparison to placebo, with average Botox dose of 165 units. Although Botox has been shown to be beneficial for headache preventive management for chronic migraine, the submitted evidence does not demonstrate that this patient has chronic migraine. Therefore, Botox is not medically necessary for this patients headache management.