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 fluorouracil toxicity and chemotherapeutic response 5 mutation testing for evaluation of his rectal carcinoma. Findings: Three physician reviewers found there are rare genetic abnormalities that affect the metabolism of 5-FU, or its derivative. One such deficiency is dihydropyrimidine dehydrogenase, an enzyme critical to the metabolizing of 5-FU. The degree of deficiency is variable such that 5-FU can still be used, in reduced doses, with certain levels of deficiency, but not with more severe degrees of deficiency. These mutations are rare, thus routine testing is not recommended prior to undergoing 5-FU treatment.  Since 5-FU is an important component of adjuvant chemotherapy for colon cancer, it would be of clinical benefit to assay this patients enzymatic status before continuing with 5-FU therapy. Given these findings, the fluorouracil toxicity and chemotherapeutic response 5 mutation testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Results:  Three reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

The parent of an eight-year-old male enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating that the enrollees condition was not emergent in nature.   Findings:  The physician reviewer found that the patient, a then seven-year-old male, presented to the emergency department complaining of an itchy rash on his arms and abdomen for one week. The rash began after the patient spent a night at a friends house, and his friend developed a similar rash.  No fever, chills, headache, neck stiffness, or nausea/vomiting were noted. Vital signs were normal and he had no pain.  He was evaluated by a physician who diagnosed him with a rash and discharged him from the ED with a prescription for hydrocortisone cream and Benadryl.  At issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, believe the patient was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. Review of the submitted evidence indicates that the patient had a rash that had been ongoing for one week. The rash was not associated with any other concerning symptoms such as fever, chills, headache, neck stiffness, or nausea/vomiting.  In addition, the rash was not painful. Thus, the patients condition was not such that a prudent layperson would reasonably conclude that the patient required treatment on an emergent basis.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for coverage for computed tomography (CT) scan of the heart with quantitative evaluation of coronary calcium. Findings:  Two of the three physician reviewers found the patient has a strong family history of early coronary artery disease with multiple close blood relatives having early coronary artery disease or myocardial infarction. She also has evidence of vascular calcium on in the abdominal aorta at a relatively young age. The use of coronary calcium scoring has been recommended as a reasonable test to better assess risk of coronary disease in this intermediate risk population, especially in light of the strong family history of early coronary artery disease. A high calcium score would provide further evidence of a higher risk of coronary artery disease and would assist in determining the need for long-term statin therapy. A calcium score of zero would provide reassurance to continue with non-pharmacological therapies and avoid lifelong statin lipid lowering therapy at this time. Calcium scoring would provide significant clinical information which could impact long-term treatment and outcomes. Therefore, the requested CT scan of the heart with quantitative evaluation of coronary calcium is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in cardiovascular disease 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 67-year-old male enrollee has requested Sovaldi and Olysio for treatment of his hepatitis C genotype 1a.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) recently approved Sovaldi, a nucleotide analog polymerase inhibitor and Olysio, an oral protease inhibitor, for treatment of patients with hepatitis C virus infection. However, this patients ultrasound did not demonstrate advanced (F3 or F4) liver fibrosis. Overall, this patient does not have significant liver fibrosis to support an indication for combination therapy with Sovaldi and Olysio. Therefore, the requested Sovaldi and Olysio combination therapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 13-year-old male enrollee have requested Sensory Integration therapy programs and services for the treatment of the enrollees autism. Findings:  Two physician reviewers found that Sensory integrative programs rely on reinforced behavioral programs that typically require many hours (2-4 hours) of intensive one-on-one training progressing to group therapy. This patient with normal intelligence and minimal speech deficit is an excellent candidate to show improvement in such an intensive therapy program. The medical literature notes the need and value of an intensive program; it also notes the need for intervention at as many hours per week as available. The proposed services are medically indicated and appropriate and likely to be of greater benefit to the patient than the specific therapies offered by the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Oxbryta (voxelotor) 500 mg tablets. The  U.S. Food and Drug Administration (FDA) describes Oxbryta (generic name voxelotor) as a hemoglobin S polymerization inhibitor indicated for the treatment of sickle cell disease. Vichinsky and colleagues reported that in a double-blind, randomized, placebo-controlled trial on the efficacy and safety of two dose levels of voxelotor with placebo, voxelotor significantly increased hemoglobin levels and reduced markers of hemolysis. In this case, the patient likely had sickle beta thalassemia disease and suffers from significant anemia. The requested medication is medically indicated in this clinical setting as it has the benefit of increasing hemoglobin. Therefore, Oxbryta (voxelotor) 500 mg tablets are medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certifications in medical oncology and hematology 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

The patient has requested authorization and coverage for bilateral turbinate reduction, septoplasty, nasal vestibular body reduction, and bilateral Latera implants. The submitted documentation supports the medical necessity of a portion of the requested services. This patient has a history of nasal obstruction. The records indicate that the turbinates are the largest contributor to his nasal obstruction. He also had septal spurs bilaterally that impede the nasal airway. Septoplasty and turbinate reduction are likely to improve the patients nasal airway. Although a nasal decongestant may provide temporary relief, a permanent improvement can be obtained with turbinate reduction surgery. In this patients case, the requested septoplasty and turbinate reduction are medically necessary. The records fail to demonstrate the medical necessity of the requested nasal vestibular body reduction and bilateral Latera implants. The Latera implant and vestibular body reduction may be indicated if lateral wall stenosis or collapse is the major issue. In this case, a Cottle maneuver was not performed to show that the lateral nasal wall was a major contributor to the nasal obstruction. Therefore, the requested bilateral turbinate reduction and septoplasty are medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xeljanz (10 mg). Findings:  The physician reviewer found that Bressler and colleagues indicate that Xeljanz has a different mechanism of action than aminosalicylates, immunomodulators, anti-tumor necrosis factor therapies, Entyvio, and Stelara. Xeljanz is approved by the U.S. Food and Drug Administration for the treatment of ulcerative colitis. In a double-blind study by Sandborn and colleagues, Xeljanz was proven effective in patients with moderate-severe ulcerative colitis, with up to 78% clinical response and 41% clinical remission at eight weeks, both significantly higher than placebo. According to Bressler and colleagues, endoscopic remission rate was also significantly higher than placebo. American Gastroenterological Association (AGA) guidelines for the treatment of ulcerative colitis state, In adult outpatients with moderate to severe ulcerative colitis who have previously been exposed to infliximab, particularly those with primary nonresponse, the AGA suggests using ustekinumab or tofacitinib rather than vedolizumab or adalimumab for induction of remission. In this case, the patient has already failed infliximab and vedolizumab for ulcerative colitis, and he has required ongoing corticosteroid therapy. Current medical literature supports the use of Xeljanz for ulcerative colitis in this case after failure of multiple other therapies. Therefore, Xeljanz (10 mg) is medically necessary for 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year, seven-month-old male enrollee has requested authorization and coverage for circumcision for treatment of the enrollees physiologic phimosis.  Findings:  The physician reviewer found that McGregor and colleagues defined phimosis as the inability to retract the foreskin. The authors discussed the importance of distinguishing physiologic and pathologic phimosis, as the former is managed conservatively and the latter requires surgical intervention. The submitted documentation demonstrates that this patient has physiologic phimosis rather than pathologic phimosis. Review of the medical literature does not establish that there is a medical necessity for routine circumcision (Wang, et al.).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested group therapy for treatment of the enrollees gender dysphoria. The patient has a recent history of psychiatric instability, and there is a lack of evidence demonstrating that the patients psychiatric status has yet been stabilized. The Health Plan indicates the patient can return to transgender group therapy once the more acute issues of suicidality and behavioral dysregulation have been stabilized. Until it is established that the patient is psychiatrically stable, she is not a candidate for transgender group therapy services as her ability to appropriately participate in the therapy will be limited. Although ongoing comprehensive psychiatric care is indicated for this patient, the requested group therapy sessions are not medically necessary for treatment of this patient at this time.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: Upheld

A 38-year-old female enrollee has requested for a dermatology consultation for treatment of her skin tags.  Findings:  The physician reviewer found that treatment of benign skin lesions is considered medically necessary when lesions display symptoms such as significant change in size, uncertain diagnosis, obstruction of an orifice, or the potential of malignant transformation. As noted by Pariser, Virtually all human beings have a number of benign cutaneous neoplasms, and the primary care provider is expected to make clinical judgments, without recourse to consultation or histopathologic examination. This patients lesions of interest do not fulfill these criteria, as provider did not document the patients skin tags to be symptomatic.
Appeal type: Medical Necessity
Decision: Overturned

A 48-old female enrollee has requested authorization and coverage for a colonoscopy for evaluation of the enrollees colon polyps and family history of colon cancer.  Findings:  The physician reviewer found that based on review of the available records, this patient had already developed adenomas at a young age. Therefore, a shorter interval may be appropriate for follow-up colonoscopy. The most rigorous guidelines for colonoscopy surveillance intervals are published in average risk populations. This patients case is unique given her familial and personal history of colon polyps, as well as her family history of colon cancer. The request for a follow-up colonoscopy at this time is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested 24 hours of psychological testing 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 requested services.  According to the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for Autism, if screening indicates the possibility of autism spectrum disorder, there are various instruments that can be employed for a more thorough assessment.  These include the Autism Diagnostic Interview-Revised, Diagnostic Interview for Social and Communication Disorders and Autism Diagnostic Observation Schedule.  The AACAP recommendation for diagnosis of attention deficit/hyperactivity disorder is a clinical interview with rating scales completed by the parents and the teachers.  These are self-administered scales that require no more than five minutes of professional time to score and evaluate.  Upon reviewing the treating therapists notes, the main concern was the patients problematic usage of language.  If this is the chief concern, a more appropriate referral would have been to a speech/language pathologist for evaluation and further treatment if indicated.  All told, the requested 24 hours of psychological testing is not medically indicated 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 with sub-specialty certification in child and adolescent 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 parent of a 12-year-old male enrollee has requested Metadate CD for treatment of the enrollees attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that stimulant medication is the gold-standard psychopharmacologic intervention for attention deficit/hyperactivity disorder.  Metadate CD is a brand name, bimodal stimulant drug which has been approved for the treatment of attention deficit/hyperactivity disorder.  There is a generic equivalent to this brand name medication called methylphenidate extended release, and it is available in either a capsule or tablet.  When a generic medication replaces a brand name, there is a possibility that there are differences in potency.  This likely explains why this patient has needed more milligrams of the generic compound as opposed to the brand name.  However, the current medical evidence does not support the requested medication in this clinical setting.  There is no evidence in the medical record that the patient has been unable to tolerate the generic medication, and he has not reached the maximum typical daily dose of methylphenidate extended release.  Further, the common practice of decompressing or augmenting the stimulant load with the addition of guanfacine has not been trialed.  All told, Metadate CD is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old transgender female enrollee requested facial feminization surgery for treatment of the enrollees gender identity disorder.  Findings:  The physician reviewer found that the World Professional Association for Transgender Health (WPATH) Standards of Care indicate that some procedures that may be considered cosmetic under some circumstances are medically necessary under other circumstances.  A specialty therapists evaluation is an essential component of that determination. In order to establish the medical necessity and/or the reconstructive nature of the requested services, there must be documentation of the following:  One or more consults or letters of support from licensed individuals with experience in transgender therapy and issues (such as a licensed Psychiatrist, Psychologist or Licensed Family Therapist) which includes: Summary of the patients mental health assessment and mental health history; Discussion of the patients gender history, gender procedure history and response to prior procedures with regard to alleviation of gender dysphoria symptoms; and assessment of current symptoms of gender dysphoria specific to the facial areas considered to be masculine and in request of therapy (i.e., To what degree does the patient experience gender dysphoria relative to her forehead/brow shape, jawline and chin, prominent tracheal cartilage, nose, and/or other specific aspects of her facial appearance?).  In the absence of documentation from a specialty clinician establishing a connection between the patients gender dysphoria and the specific areas of treatment, the medical necessity and/or reconstructive nature of the requested services cannot be established at this time. Once the above information is obtained, the patient's request for facial feminization surgery should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested mental health acute inpatient treatment for the treatment of the enrollees anxiety and depression. Findings:  The physician reviewer found that the acute inpatient treatment services were medically necessary, as the patient required this level of care to effectively engage in treatment for severe anxiety and depression, and to initiate and monitor psychotropic medication. Her severe anxiety, withdrawn behavior, somatic complaints and inability to tolerate school even for one hour per week, significantly limited the patients ability to attend and engage in less restrictive services such as a partial hospitalization program.