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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in diagnostic accuracy and detection of small cancers compared to 2D imaging alone. Thus, the addition of tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three 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 number one, two, and three are board certified in diagnostic radiology and 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 52-year-old female enrollee has requested a right breast scintimammography (the exam at issue is actually lymphoscintigraphy) for evaluation of her newly diagnosed right breast neoplasm.  Findings:  Three physician reviewers found that this patient underwent a lymphoscintigraphy prior to sentinel node (SN) dissection. There is support in the peer-reviewed literature for the performance of lymphoscintigraphy prior to SN dissection. Specifically, Krynyckyi and colleagues found that, The ultimate goals are to delineate the true SN, maximize activity in the node for facilitated removal (even at next-day surgery). In addition, van der Ploeg and colleagues concluded that, SPECT/CT shows the exact anatomical location of sentinel nodes, detects sentinel nodes not depicted by conventional imaging, and therefore facilitates surgical exploration. Further, Husarik and Steinert reported that, localization and identification of sentinel lymph nodes was more accurate by integrated SPECT/CT imaging in comparison with planar images and SPECT images. As in this patients case, the peer reviewed medical literature supports the utility of the lymphoscintigraphy exam in assisting the treating physician in surgical planning prior to SN biopsy. Therefore, the lymphoscintigraphy at issue was likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested implantation of the X-Stop interspinous device for treatment of his spinal stenosis. Findings:  Two physician reviewers found that the X-Stop procedure is intended to address neural foraminal stenosis of moderate degree. The literature supports the more traditional posterior laminotomy in patients with severe spinal stenosis, which is not present in this patient. The rationale for the X-Stop device is that neural foraminal stenosis and intervertebral disc pressures will be influenced by the device. The anatomical studies published to date document an increase in the cross sectional area of the neural foramen and a decrease in interdiscal pressures, but these anatomical changes do not continue over time, and there is a reversion to the preoperative dimensions of the neural foramen and the intervertebral disc pressures. Pain generators are present within the annuli of the intervertebral disc and within the facet joints themselves. Additionally, inflammatory processes within the posterior ganglia and spinal nerve root structures are recognized as likely pain generators. The literature of the outcome of the X-Stop procedure published to date relies heavily on patient scored subjective scoring, including the Oswestry Disability Index and the Brigham Low Back Pain Questionnaire. There are issues of patient selection bias in the prospective studies reported to date, and the placebo effect has not been adequately addressed. The control groups receiving conservative management are poorly defined, particularly in reference to specificity in the conservative treatment protocols. There is evidence that increased dimensions of neural foramina and decreased interdiscal pressures initially present are lost over time. Longer term studies with improved criteria to assess patient and provider selection bias and more accurate definition of conservative protocols serving as controls are needed before the efficacy of the X-Stop procedure can be reliably determined.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a COVID-19 test. As reported by the Centers for Disease Control and Prevention (CDC), the symptoms required for COVID-19 polymerase chain reaction (PCR) testing have varied since the onset of the pandemic. Per the California Department of Public Health (CDPH) guidance, this patient does not meet the criteria for COVID-19 testing. The guideline notes that patients with mild respiratory symptoms who do not otherwise need medical care...should not be routinely tested for COVID-19. This patient reports symptoms including shortness of breath and a mild cough. On physical examination, the patient did not have a fever or significant cough. The patient has comorbid asthma, which is another condition that would account for his shortness of breath. Based on the current recommendations from the CDC and CDPH, the requested COVID-19 test is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage of speech therapy services. In the medical literature, it is recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. The authors noted that further development of therapy plans and interventions targeting pragmatics is strongly needed. Researchers estimated that 44% of children with autism are bullied at school. The authors reported that this is frequently due to patients difficulty interacting appropriately with others. Researchers discussed methods of exploring deficits in pragmatic language in children with autism using the Pragma test, the Social Interaction Deviance Composite of Childrens Communication Checklist-2, and the Theory of Mind subtest of the Developmental Neuropsychological Assessment, Second Edition. The results showed that children with autism differed from typically developing children in questions demanding context utilization. This patient has autism and mild-to-moderate sensorineural hearing impairment. He has deficits in articulation and in the appropriate social use of pragmatic language. With significant impairment in his pragmatic language and articulation, he will have difficulty interacting with his peers and navigating his was through activities of daily living. Given the support in current literature, the requested speech therapy services twice weekly are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 neurology with special qualification in child neurology and in pediatrics, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested authorization and coverage of open reduction internal fixation (ORIF) for the treatment of a shoulder fracture.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.The parent of a five-year-old male enrollee has requested 30 hours per week of applied behavioral analysis therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that applied behavioral analysis (ABA) is an established medical treatment modality widely accepted in the practicing community and by centers specializing in treating ASD. According to an article published in the October 2008 edition of Child and Adolescent Psychiatric Clinics of North America, ABA is a state of the art treatment modality for this medical disorder. The authors note that ABA utilizes methods derived from scientifically established principles of behavior and intensive treatment is needed, usually between 20-40 hours per week. The National Institute of Mental Health also acknowledges that ABA has become widely accepted as an effective treatment for autism. This finding is consistent with the Surgeon Generals report on Mental Health. Granpeeshehs July 2009 article notes that ABA treatment programs are supported by scientific evidence and are recommended for individuals with autism. Review of the submitted clinical evidence reveals that the patient has made progress with ABA therapy. All told, there is adequate evidence demonstrating that ABA services at a frequency of 30 hours per week are likely to be superior to any other available treatment for this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospital services for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Based on the medical records, adequate services could not have been delivered in a less restrictive setting at the time.  The patient had a very serious complex addictive disorder.   The services at issue were for active treatment delivered in accordance with a treatment plan and reasonably expected to improve the patients condition.  Finally, the hospital admission facilitated a seamless transfer to a residential chemical dependency program which mitigated the highly probable risk of relapse facing this patient in an unsupervised setting.  In sum, the inpatient hospital services were medically necessary for the patients medical condition.   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 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: Overturned

A 63-year-old female enrollee has requested CombiPatch for treatment of her status postmenopausal.  Findings:  The physician reviewer found the submitted documentation supports the requested medication in this enrollee's case.  As noted by the American College of Obstetricians and Gynecologists Committee Opinion 556, medroxyprogesterone may have an increased risk of causing blood clots compared to some other progesterone preparations.  However, it was noted that the transdermal route may be less risky than the oral route.  In this enrollee's case, she has tried oral hormone replacement therapy and experienced side effects.  She reportedly has done well with CombiPatch.  There is sufficient support for the requested medication in this clinical setting.  All told, CombiPatch is medically necessary for the treatment of this enrollee.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested a plastic surgeon consultation for therapeutic reduction mammaplasty for treatment of her chronic back pain.  Findings:  The physician reviewer found that based on the patients complaints and the medical records provided, there is sufficient documentation that a functional deficit from breast enlargement may be present.   Symptomatic macromastia is documented as the patients ADLs are affected and physical therapy has been attempted. As confirmed by the Health Plan, shoulder grooving from bra straps is documented. As stated from the American Society of Plastic Surgeons (ASPS), Based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. Overall, a patient should undergo evaluation for possible mammaplasty with documentation of at least two symptoms regardless of body weight or weight of breast tissue removed. These symptoms include breast hypertrophy, chronic breast pain due to weight of breasts, upper back/neck/shoulder pain, and shoulder grooving from bra straps. This patient presents with more than two of these symptoms including shoulder grooving, back pain, and a diagnosis of breast hypertrophy. As plastic surgeons are uniquely qualified to evaluate symptomatic macromastia and the suitability for surgical treatment, these specialists may be able to provide greater detail and explanation with respect to the patients other functional concerns. This could help to identify a true functional deficit that may be improved with surgical reduction.  In summary, based on the ASPS guidelines and the above references, this patient has a functional problem that could be successfully treated with breast reduction surgery. The patient and primary care provider have provided confirmatory documentation of a functional problem and this should be evaluated by a plastic surgeon to determine whether surgical intervention is in fact indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Urgent PC (tibia neurostimulation). Findings:  Two of the three physician reviewers that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation (PTNS) in patients with urinary urgency and frequency. However, most trials have a small number of patients with short term follow-up. Current guidelines recommend that providers should offer behavioral therapies, including bladder training, bladder control strategies, pelvic floor muscle training, and fluid management, as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral anti-muscarinic therapy or oral 3-adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. The guidelines rate PTNS as a third-line therapy. There are alternative treatments, including Botox injections and sacral neuromodulation. The use of PTNS has not been proven to be superior to other alternatives. Studies have compared PTNS to anticholinergics and have demonstrated comparable efficacy. There is a lack of head-to-head trials comparing sacral nerve stimulation to PTNS. Thus, PTNS has not been shown to be superior to sacral nerve stimulation. Therefore, the requested Urgent PC (tibia neurostimulation) is not likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested services 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: Urgent Care
Decision: Upheld

A 37-year-old female enrollee has requested urgent medical and laboratory services for the treatment of her medical condition. Findings:  The physician reviewer found that according to California regulations, 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 enrollee returns to the Plans service area. The Health Plan defines urgent needed care as any otherwise covered medical service that a reasonable person with average knowledge of health and medicine would seek for treatment of an injury, unexpected illness or complication of an existing condition, including pregnancy to prevent serious deterioration of his or her health, but which does not qualify as Emergency Care.  This patient presented with amenorrhea after discontinuation of oral contraceptive. She sought examination with an out-of-network provider. There is no objective documentation of pelvic or abdominal pain and no evidence of an evaluation of pain. There is no evidence of an urgent or emergent problem. The laboratory tests ordered were not of an urgent or emergent nature. The submitted clinical evidence does not demonstrate the presence of an unforeseen illness, injury, or complication of an existing condition. Further, the services provided were not necessary to prevent serious deterioration of the patients health and could have been delayed until the patient returned to the Plans service area.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his metastatic sarcoma to the lungs. Findings:  Three physician reviewers found that local therapy is indicated because the lung is the only site of disease.  Surgery is not an option because further resection would likely severely compromise lung function.  Chemotherapy is a standard treatment for metastatic disease, although patients with sarcoma (particularly relatively indolent sarcomas) respond poorly to chemotherapy. In this clinical situation, the requested CyberKnife stereotactic radiosurgery is likely to be superior to any other therapy available in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested Marinol (dronabinol) for medical treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the use of Marinol in this clinical setting.  Marinol is approved for the treatment of chemotherapy-associated nausea and vomiting refractory to other anti-emetics and acquired immune deficiency syndrome (AIDS) related anorexia.  Marinol is not approved for the use of nausea associated with chronic pancreatitis or familial adenomatous polyposis.  There is a lack of support for Marinol for the treatment of this patient.  All told, Marinol is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 24 weeks of Harvoni for treatment of her chronic hepatitis C virus genotype 1.  Findings:  Three physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. Therefore, although Harvoni is clinically appropriate in this setting, the requested duration of 24 weeks of therapy is not medically necessary given the support in the guidelines which recommends treatment with Harvoni for 12 weeks. Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.