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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Myomo (MyoPro) Motion-G elbow-hand orthosis.Findings:  Three physician reviewers found that the requested device is not indicated under these circumstances. The medical literature regarding this type of device is limited to preclinical work, developmental work, and small anecdotal reports of potential for benefit, some of which is industry-sponsored work. While this type of device can provide some functional benefits theoretically, it is not known whether users will adopt the device for regular functional use in the long-term (i.e., for use beyond the short-term as a novelty device), or if the device itself causes injuries with long-term use (e.g., at the shoulder due to the devices not insignificant weight). Many commercially available iterations of this type of device remain heavy, bulky, difficult to don, and difficult to use on a practical basis. It is unknown whether the requested device would exacerbate arm lymphedema or the constant neuropathic pain that this patient has and uses opioid analgesics to manage. Further study of an unbiased nature is required to better understand adoption of the device into actual functional use outside of research settings, and to establish safety. Although the patient has severe impairments that are not expected to improve with any further conventional management, the requested device is not reasonably expected to favorably impact the enrollees long-term clinical or functional outcomes. Therefore, the requested device is not likely to be more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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

A 30-year-old male enrollee has requested uvulopalatopharyngoplasty (UPPP), removal of tonsils, septoplasty and resection of the inferior turbinates for treatment of his medical condition.  Findings:  The physician reviewer found that in this patients case, polysomnography performed on the date indicated showed evidence of obstructive sleep apnea.  Follow-up titration of continuous positive airway pressure was performed and a maximum pressure of 16 cm of water was found to alleviate symptoms of obstruction.  However, the submitted records do not include documentation of a length of trial of CPAP therapy nor of any effectiveness of the CPAP in reducing the symptoms of daytime somnolence.  In order to establish the medical necessity of the UPPP, the medical record must document that the patient has undergone appropriate trial of CPAP therapy prior to surgical intervention.  Uvulopalatopharyngoplasty is a surgical intervention that incorporates removal of the tonsils in addition to sections of the soft palate.  Tonsillectomy is a definitive complement of that intervention which is also not medically necessary. According to the clinical notes, the patient was found to have functional nasal airway obstruction secondary to deviation of nasal septum with some degree of inferior turbinate hypertrophy.  However, the records do not document medical therapeutic attempts with the use of topical nasal medications.  The documentation fails to establish the medical necessity of the requested septoplasty and resection of the inferior turbinates.  Given the lack of documentation of failure of adequate control of the patients symptoms with medical therapy or CPAP, the requested services are not medically necessary.  All told, the requested uvulopalatopharyngoplasty (UPPP), removal of tonsils, septoplasty and resection of the inferior turbinates are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of a muscle stimulator.  The Health Plan denied the request indicating that the requested device is not medically necessary for the treatment of the enrollees left knee muscle weakness.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested device is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV.  Moreover, per AASLD/IDSA guidelines for high priority treatment include patients with fibrosis of Metavir F2. This patient has advanced disease and hence, treatment is medically necessary. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two 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
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper airway stimulation (UAS) device for the hypoglossal nerve for treatment of the enrollees obstructive sleep apnea syndrome. Findings:  The physician reviewer found that The medical literature and the submitted documentation demonstrate the medical necessity of the requested device. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three and four year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial demonstrated that hypoglossal nerve stimulator was safe and effective in a small subset of patients with OSA who had  failed CPAP.  In this patients case, he meets the criteria for placement of this device. The patient has a BMI of 22.6, AHI of 50 and nonconcentric airway collapse. The patient has failed CPAP, which is the gold standard treatment for OSA and is at risk for untoward cardiac sequelae of untreated OSA. Therefore, the UAS device for the hypoglossal nerve is medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Flector patch. Findings:  The physician reviewer found that the documentation does not support the medical necessity of the requested medication in this clinical setting. The medical literature indicates that non-steroidal anti-inflammatory medications (NSAIDs) are contraindicated in patients who experience side effects of gastrointestinal irritation due to increased risk of gastric ulcers and gastric perforation. In this patients case, there is no documentation of gastrointestinal irritation with NSAIDs. Authors of a study performed a systematic review to address and summarize the evidence of the effectiveness and safety in topical NSAIDs. The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on their molecule and the formulation chosen. In acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDS. The authors performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo. They found that there was limited trial data to support the long-term use of topical NSAIDs in osteoarthritis. Therefore, Flector patch is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee has requested intensive outpatient program (IOP)  for treatment of his substance abuse.  Findings:  The physician reviewer found that this patient has mood symptoms and anxiety, but these symptoms are likely related to or secondary to his drug use. The records suggest he is stable on an atypical antipsychotic medication for his psychiatric problems. However, the patient does struggle with profound addiction pathology. He is prescribed buprenorphine for his diagnosis of polysubstance dependence. His characterological organization and addictive illness places him at high-risk for overdose. The records indicate the patient currently lacks the fortitude to champion his drug problem independently. In the absence of IOP treatment, the patient is likely to relapse and require clinical services in a more restrictive setting. This patient requires a period of sustained sobriety along with improved insight, optimization of his psychosocial support system and enhanced coping strategies to impart meaningful change and foster independent, successful and drug-free living. Thus, the IOP services at issue were and are medically necessary for treatment of the patients medical condition from the date indicated and forward.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services.  Findings:  The physician reviewer found that upon presentation, the patient was intoxicated and at high risk for an alcohol withdrawal syndrome. He had been drinking regularly for about eight months and consuming up to two bottles of wine per day for the previous week. He was mildly hypertensive and tachycardic. Based on this clinical data, admission for supervised detoxification was safe, appropriate and consistent with good medical practice. However, although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the RTC level of care following detoxification. On admission, the patient had a normal mental status examination. He had no acute psychiatric issues or medical comorbidity that would warrant service delivery in a RTC setting. His alcohol related medical sequelae were non-emergent and would not be expected to improve to any greater degree in a RTC setting as opposed to the outpatient venue. He expressed motivation for recovery and he was committed to treatment and his spirituality. The patients wife and children were supportive and he had safe housing. The patient had good success in the past with outpatient services and community-based programming. Further, he had no prior treatment during the episode of illness, such as anti-craving medications, sober living environments, IOP or partial hospitalization program treatment. In sum, the records do not reflect that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been unsafe or inadequate. Thus, the RTC services were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an additional four hours (three hours/units  96133; one hour/two units 96137) of neuropsychological testing (for a total of 13 hours testing)At issue is whether the additional four hours (three hours/units  96133; one hour/two units 96137) of neuropsychological testing (for a total of 13 hours testing) are medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The issue of neuropsychological testing for the diagnosis of ADHD has come up for debate in recent years, despite being the accepted modality for diagnosis previously. The medical literature indicates that it is no longer standard of care to refer for neuropsychological testing for a diagnosis of ADHD but instead, the diagnosis is meant to be made based on objective measures as well as clinical/psychiatric evaluation. In this case, the Health Plan has already authorized nine hours of testing. Despite the patient not yet receiving testing, his psychiatrist has already started Strattera for presumed ADHD based on clinical evaluation. The requested additional four hours (three hours/units  96133; one hour/two units 96137) of neuropsychological testing (for a total of 13 hours testing) are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, four additional hours (three hours/units  96133, one hour/two units  96137) of neuropsychological testing (for a total of 13 hours testing) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested excision skin infraumbilical panniculectomy for treatment of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  There is evidence of a symptomatic lower abdominal pannus in association with abdominal hernias.  Her symptoms include abdominal pain treated conservatively with narcotic analgesia and chronic rashes/irritation treated topically.  Her examination and photographs are supportive of a large overlapping abdominal pannus, contributing to her functional deficits of pain and chronic irritation/infection.  This has been documented to affect her activities of daily living.  This is supported by documentation from her treating providers.  In this patients case, the panniculectomy can provide adequate exposure for the repair of multiple hernias and allow for resolution of her functional complaints of pain and chronic, recurring rashes.  The weight and size of her pannus is directly affecting her activities of daily living with mobility, resulting in chronic pain and recurring irritation.  Panniculectomy would likely directly address these deficits.  All told, the requested excision skin infraumbilical panniculectomy is medically indicated for the treatment of this patient.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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of her neck and back pain and headaches. The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested medication. A review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition. In addition, the article by Obermann and colleagues on pharmacotherapy options for cluster headache (CH) notes International treatment recommendations and official guidelines give reassurance about specific pharmacotherapy options for CH, but only few of these are backed by sufficient scientific evidence. In this case, the patient has a history of longstanding chronic neck pain, low back pain and headaches. The patients provider has recommended multi-modal therapies to include imaging and physical therapy. However, according to the documentation submitted for review, there is a lack of documentation demonstrating that the patient has tried and failed the multi-modal therapies recommended. All told, the medical necessity of the requested medication has not been established in this clinical setting.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 72-year-old female enrollee has requested finger joint manipulation under anesthesia for treatment of her persistent flexor tenosynovitis with locking and contracture of the left thumb. Findings:  Three physician reviewers found that the records do not detail whether she has fixed joint contracture and/or simply developed a contracture through disuse. There is no indication that surgical manipulation would have provided this patient any additional benefit beyond that which would have been anticipated from the trigger thumb release procedure. In the absence of well designed, quality peer-reviewed medical studies, the use of manipulation under anesthesia in this clinical setting is without proven efficacy. Overall, the literature does not support the use of manipulation as a treatment that is likely to be more beneficial than traditional measures for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a history of breast cancer. The patient has undergone bilateral salpingo-oophorectomy and mastectomy. Both the patients mother and daughter died of breast cancer under the age of 50. A request has been made for BRCA 1 and BRCA 2 genetic testing. The Health Plan has denied the request indicating that BRCA genetic testing is not medically indicated for the patient.The Health Plans denial should be upheld. Although the patient has a family history of breast cancer the patient has already been diagnosed with breast cancer and has undergone bilateral mastectomy and bilateral salpingo-oophorectomy. Thus, BRCA testing will not alter her future treatment. While BRCA genetic testing may be indicated for the patients daughter, it is not medically indicated for the patient herself. Therefore, I have determined that the requested services are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee requested authorization and coverage for transurethral microtherapy heat treatment (TUMT).  The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees benign prostate hypertrophy.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.