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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transperineal placement of a SpaceOAR Hydrogel (CPT 55874). Modern radiotherapy employs dose escalation to maximize efficacy. Since the rectum lies in close proximity to the prostate, the risk of rectal toxicity is high without the use of a perirectal spacer. The use of SpaceOAR Hydrogel is considered standard of care per the current peer-reviewed medical literature in this patients clinical setting. One prospective randomized controlled trial demonstrated that the use of SpaceOAR in conjunction with radiation delivery significantly decreased bowel, urinary, and sexual morbidity as compared with radiation treatment without the use of SpaceOAR. Moreover, the recent NCCN guidelines for the management of prostate cancer support the utility of perirectal spacers to reduce high-grade acute and late rectal toxicity. This patient has no evidence for transcapsular extension, which is a contraindication to SpaceOAR use. Therefore, the requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) is 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 requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation 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: Medical Necessity
Decision: Overturned

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C virus genotype 1a.   Findings:  Two physician reviewers found that the selection of a hepatitis C virus antiviral regimen for patients with renal disease depends upon the extent of renal impairment, genotype, extent of underlying liver disease, and history of past antiviral treatment. Levels of sofosbuvir and its metabolite are substantially higher in patients with severe renal impairment or end stage renal disease on dialysis than in patients who have normal renal functions, so the safety of sofosbuvir-containing regimens in such patients has not been established. Viekira Pak is considered a safer alternative for patients with severe renal impairment. For treatment-naive patients, the duration of Viekira Pak and the addition of weight-based ribavirin depend on the infecting subtype and the presence of cirrhosis. Consistent with these findings, the requested Viekira Pak is medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested a referral to an out-of-network provider for repair of the sternum for the treatment of his acquired pectus deformity. Findings:  The physician reviewer found that the patients condition does constitute an abnormality of a bodily structure due to a malignant process (i.e., multiple myeloma) with subsequent bony destruction and likely fracture. It appears the primary goal of the requested surgery appears to be to create a normal appearance to the extent possible. However, due to the possibility of persistent myeloma as well as cortical weakness of the sternum, the proposed procedure is unlikely to achieve this goal if performed currently. Although there may be a time in the future with further treatment of the myeloma and therapy to restore bone loss in which the likelihood of success is greater, the proposed surgery is not likely to result in more than a minimal improvement in appearance at this time. Therefore, the requested sternum repair is not considered reconstructive surgery as defined by California law. Furthermore, the submitted clinical evidence does not demonstrate that the requested procedure is indicated based on general concepts of medical necessity. Current indications for sternum repair would include improving functional limitations, ensuring stability of the bone and maintaining acceptable cosmesis. Based on the clinical evidence provided, it is not clear that the patient suffers pulmonary dysfunction due to the deformity. Nor are there any clinical signs of instability documented in the submitted records. Moreover, it is not clear that the patients symptom of pain will be improved by the proposed repair. As such, medical necessity criteria for surgical repair of the patients sternum have not been met.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee requested hospital admission for medical treatment of her vomiting and dehydration during pregnancy.  Findings:  The physician reviewer found that the patient presented to the ER and was found to be dehydrated from protracted nausea and vomiting. The patient had an electrolyte imbalance as well as a markedly elevated urine specific gravity and ketonuria which is consistent with severe dehydration. In addition, she presented with an elevated temperature of 100.4 F and bandemia (immature white blood cells) on the manual differential, suggesting a possible underlying infection. An attempt at IV hydration in the ER with two liters of fluid was undertaken with the patient still symptomatic. The patient was admitted to the hospital for further observation with documentation of administration of IV fluids with electrolyte replacement and IV antiemetics. In this clinical setting the patient could not have been managed at a lower level of care. The patient was evaluated and diagnosed with dehydration in the ER and to have transferred the patent home with home IV therapy at that point, even if it could have been arranged would have been outside the standard of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested OnDose testing for evaluation of his colon cancer.  Findings:  Two physician reviewers found that OnDose assay is a blood test that analyzes certain genetic variations within an individual that will indicate that persons sensitivity to 5-FU chemotherapy, a component of the FOLFOX regimen.  This would theoretically allow the clinician to individualize the 5-FU dose, decreasing toxicity and increasing efficacy. Gamelin and colleagues demonstrated that when dosing was guided by OnDose, there was less toxicity, a higher response rate and a trend towards better survival, although this was not statistically significant. However, the 5-FU in that study was not used in the FOLFOX schedule and protocol.  Therefore, one cannot apply this study to this patient.  Furthermore, OnDose testing is not within the current National Comprehensive Cancer Network guidelines for the treatment of metastatic colon cancer.  In sum, there is a lack of data supporting the use of OnDose testing for improving survival in this clinical situation.  All told, the superior efficacy of OnDose testing has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female, with lower back pain, requested authorization for epidural steroid injections provided by a pain management specialist.Reviewers findings:The reviewing physician found that the documentation provided for review did not indicate a need for further epidural steroid injection therapy. There was no note of radicular symptoms or findings on neurological examination. The patient needed be re-evaluated by her PCP prior to any referral for additional interventional therapy. The patient might possibly benefit from additional medical therapies and neurosurgical consultation may be appropriate given the MRI report.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The submitted documentation supports the medical necessity of the services at issue and the requested services. The American Psychiatric Association (APA) guidelines for major depressive disorder note that admission to an intensive day program may be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. The APA treatment guidelines for substance use disorders recommend that care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.In this case, the patient stated that he was, [G]ood at covering his depression until it was too late and reached a crisis point, thereby indicating that he was not able to manage his depression without support and guidance. The patient also stated that cannabis took over his life. The patient indicated that he was concerned about his depression and how it led to cannabis use. He also acknowledged that cannabis use then worsened his depression. He explained that he wanted to be able to maintain self-control, i.e. not use drugs, at moments of peak crisis. The patient improved with intensive outpatient services three times a week, but he was at times teetering, given the severity of his illness and the poor quality of his support outside. Accordingly, the IOP services that the patient received were in accordance with generally accepted standards of medical practice and were clinically appropriate for his illness. Under these circumstances, the intensive outpatient program (IOP) services provided to the patient were and are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and the requested services were and are 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with pleuritic chest pain who was prescribed Vioxx by his cardiologist and primary physician. The patient has a past history of gastroesophageal reflux disease (GERD), hypertension, and hypercholesterolemia. The patient has a history of pericarditis in 1980. Electron beam CT scan of the chest and coronary arteries showed normal lung tissue and pleura as well as a normal coronary calcium score. The patients cardiologist determined the patients chest pain was pleuritic and prescribed Vioxx. The Health Plan has denied authorization for Vioxx indicating that there is no documentation that the patient had tried alternative low risk NSAIDs.At issue is whether Vioxx is medically necessary for treatment of the patients pleuritic chest pain. Standard treatment for pleurisy is non-steroidal anti-inflammatory drugs (NSAIDs). The patient was initially prescribed Vioxx, which is a COX-2-specific NSAID. The patient has not been shown to have any indication for initial therapy with a COX-2-specific NSAID such as Vioxx. COX-2 specific NSAIDs do not have better efficacy than non-specific NSAIDs in relieving pleuritic chest pain. The standard treatment is generally ibuprofen or indomethacin. There are also NSAIDs with low GI risk available, such as Relafen or Lodine. Based on the submitted evidence, there is no medical indication for use of Vioxx in this case. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee requested a  hospital stay for treatment of her pregnancy.  Findings:  The physician reviewer found that the patient presented to the labor and delivery department with an acute history of an abnormal NST. The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is considered a good indicator of normal fetal autonomic function. Loss of reactivity is most commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidemia. The NST results are categorized as reactive or nonreactive. As noted by the American College of Obstetricians and Gynecologists (ACOG), the most common definition of a reactive, or normal, NST is if there are two or more fetal heart rate accelerations within a 20 minute period. A nonreactive NST is one that lacks sufficient fetal heart rate accelerations over a 40 minute period. In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result may be performed by induction of labor, with continuous intrapartum monitoring of the fetal heart rate and uterine contractions. The finding of an abnormal fetal heart rate pattern, including tachycardia and arrhythmia in this patient, may indicate fetal distress. Fetal distress is an emergent condition requiring acute care of the mother and fetus. The records indicate this patent required inpatient admission to undergo obstetrical triage at this facility. However, the patient could have been evaluated at an adjacent obstetrical triage unit prior to consideration for immediate inpatient admission. If abnormal fetal surveillance was found at that time, then the patient could have been admitted for acute management. Consistent with these findings, the hospital stay was not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 47-year-old male enrollee has requested urgent care services for treatment of his complaint of body ache, insomnia and coughing. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the patients circumstances would believe they were experiencing an urgent medical condition. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plans service area.Review of the record demonstrates that the patient had symptoms most compatible with a routine viral syndrome with bronchitis. The records provided do not substantiate the presence of chest pain. In the absence of evidence of fever or chest pain, a prudent layperson would not be expected to construe this as a medical situation that required urgent attention to prevent serious deterioration of his or her health. A prudent layperson in this setting would have coordinated care through his primary care provider.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing services, DecisionDx-Melanoma. In this case, the patient had a diagnosis of melanoma. The results from the service at issue would not have changed the management of this patients thin tumor, which involved a wide local excision and further clinical skin and lymph node surveillance. The National Comprehensive Cancer Network (NCCN) does not recommend the service at issue in the management of thin melanomas and reports that the results from such testing may be inconclusive and are unsubstantiated. Swetter and colleagues note that diagnostic molecular techniques are still largely investigative and while they may be appropriate as ancillary tests in equivocal melanocytic neoplasms, they are not recommended for routine diagnostic use in the setting of cutaneous melanomas. For non-ulcerated tumors transected at a depth of less than 0.8 mm, a reasonable approach would be to perform a repeat biopsy to assess the residual disease. If the subsequent specimen does not reveal a tumor, the recommended treatment and staging may be based on the original Breslow depth. Therefore, genetic testing services, DecisionDx-Melanoma, were not likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the genetic testing services, DecisionDx-Melanoma, at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for the evaluation 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 dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the wound product Oasis for treatment of his medical condition.   Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  This patient presented with a non-healing venous stasis ulcer of the left lower extremity.  Mostow and colleagues reported a multicenter randomized, controlled trial of standard care compared to the Oasis wound matrix and noted an improved healing rate as well as a durable healing.  The comprehensive data on wound matrices for the treatment of venous stasis ulcers when combined with debridement and compression demonstrate efficacy for improved and durable healing of the ulcers.  All told, the wound product Oasis was likely to have been superior over other treatment options.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in surgery 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

The patient is a 52-year-old male who has a long history of low back pain. He was previously seen by a neurosurgeon in April 2005, and his symptoms improved with conservative therapy.  The patient had an MRI of the lumbar spine in April 2005, which showed degenerative disc disease at L4-5, and grade l spondylolisthesis at L5 with a disc bulge and neuroforaminal narrowing.A clinical note dated March 2006 states that the patient has pain in his upper back that radiates to his right shoulder.  The note states the pain is chronic, but the exact duration is not documented.  It is stated that the patient has had physical therapy, but the duration is not documented. No other conservative therapeutic measures are documented.  A follow-up appointment with the neurosurgeon was made and MRIs of the cervical and thoracic spine was ordered.  Follow-up MRI of the lumbar spine is also being requested but it is unclear from the notes by whom.At issue is whether MRIs of the cervical, thoracic and lumbar spine are medically necessary for evaluation of the patients back pain.According to the notes provided, a follow-up appointment with a neurosurgeon has been scheduled. It has been clearly established that the information gained from MRI of the spine is vital in evaluating complicated back pain. The patient has had a prior MRI of the lumbar spine, which is important for comparison to any subsequent exams. However, the next appropriate step in the diagnosis and treatment of the patients back pain would be a follow-up evaluation with a neurosurgeon. The neurosurgeon can then determine the precise diagnostic studies that are indicated based upon the patients history and a physical examination of the patient. As such, the requested MRIs are not medically warranted at this time.Based upon the information set forth above, I have determined the requested MRIs are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 30-year-old male enrollee has requested the Ensure supplement for the treatment of the enrollees anorexia. Findings:  The physician reviewer found that there is no indication in the submitted clinical records that the patient cannot eat. The normal albumin level indicates that the patient is not malnourished. Additionally, he was noted as well-nourished, and his weight has been stable. The above cited website by the Williams Syndrome Association indicates that feeding difficulties tend to resolve as children get older. The patients weight of 108 pounds is only slightly below average when using a weight chart specific for male Williams Syndrome patients. The documentation does not suggest that the patient is unable to take other forms of nutrition, even if the Ensure is responsible for his current state of health.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested cryosurgical ablation of the prostate for treatment of his prostate cancer.  Findings:  Three physician reviewers found that while the cryosurgery procedure has merit in low-stage and low-grade prostate cancers there is insufficient evidence-based literature to support the application of cryosurgical ablation in the treatment of high-grade (Gleason 4+4), bilateral disease with a PSA of 50. The procedure is not a standard form of therapy for a patient with these clinical indications. Cryosurgery is an accepted therapy for radiation failures and for initial low-grade, low-stage prostate cancer. Typically, this would mean a PSA less than 10 and a Gleason score lower than 7. There is no data showing a benefit for patients with high grade-cancers such as this patient. It is very unlikely a patient with these indications would benefit from any form of local therapy due to micrometastases and/or locally advanced disease.