Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injection, with aspiration. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injection, with aspiration is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400/100 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b.Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Per the prescribing information approved by the U.S. Food and Drug Administration (FDA), Epclusa can be taken with omeprazole 20 mg with a four-hour time spacing. Delay in treatment may result in decreased survival. Given this support, the requested Epclusa 400/100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for fat grafting to the hips.At issue is whether fat grafting to the hips is medically necessary to treat the enrollees gender dysphoria as defined in Health and Safety Code section 1374.72(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.World Professional Association for Transgender Health (WPATH) lists body contouring procedures as treatment for gender dysphoria. WPATH indicates, For the male-to-female (MtF) patient, surgical procedures may include nongenital, nonbreast surgical interventions: facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various aesthetic procedures. WPATHs Position Statement on Medical Necessity of Treatment states, Non-genital procedures are routinely performedthese surgical interventions are often of greater practical significance in the patients life than reconstruction of the genitals.In this case, the patient has sufficient documentation for the proposed procedure. In this patients case, fat grafting to the hips is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is 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. Therefore, the requested fat grafting to the hips are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 psychiatry with expertise in transgender medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Lemtrada infusion for treatment of her medical condition.  Findings:  The physician reviewer found that Lemtrada is U.S. Food and Drug Administration (FDA) approved for patients who have tried at least two previous therapies for treatment of MS which have failed. Based on the documentation submitted for review, it is not clear that the patient has failed treatment with Gilenya as she has not consistently been on the medication. Her last documented relapse which prompted the switch to Lemtrada, occurred soon after re-initiation of Gilenya. In this case, the patient has highly active disease and needs aggressive therapy. However, treatment with Gilenya has not been used consistently. Moreover, most providers reserve Lemtrada for the most refractory cases due to its significant serious side effects. Given the clinical documentation submitted for review, the medical necessity for Lemtrada infusion has not been established in this clinical setting. 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 neurology 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: Overturned

An enrollee has requested reimbursement for four Barrx Ablation Procedures that have been performed, and has requested authorization and coverage for the Barrx ablation procedure. Patients with family history of esophageal cancer have a predilection for esophageal cancer themselves. The risk of esophageal cancer in a patient with two first-degree relatives who have esophageal cancer (defined as familial Barretts esophagus) increases markedly, by over ten-fold in some studies. Expert opinion on ablation of non-dysplastic Barretts recommends ablation in patients with family history of esophageal cancer. The American Society of Gastrointestinal Endoscopy considers ablation to be a preferred management option in patients with family history of esophageal cancer. Known precursors to esophageal cancer such as Barretts Esophagus should be addressed when present in a patient with two first-degree relatives with esophageal cancer. In this case, the patient has had three relatives with esophageal cancer. The ablations performed in this case were performed until the visible Barretts esophagus was eradicated, so multiple sessions were appropriate. Accordingly, the four Barrx Ablation Procedures that have been performed, as well as the requested Barrx Ablation Procedure, were, and are, likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue, as well as the requested services, were, and are, likely to be more beneficial than any other available standard treatments for this patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in gastroenterology, 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 37-year-old female enrollee has requested authorization and coverage for hospital grade electric breast pump for treatment of her breastfeeding.  Findings:  The physician reviewer found that the current recommendation is for exclusive breastfeeding for six months. This patient is attempting to follow these guidelines as recommended by the World Health Organization (WHO) and her provider, but she requires use of a hospital grade breast pump in order to produce sufficient milk for her child who was born with a congenital oral abnormality. Since she does not produce sufficient milk with a commercial pump, which necessitates use of infant formula, a hospital-grade breast pump is medically necessary and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female has requested a QCT bone density study for the evaluation of osteoporosis.  Findings:  The physician reviewer found that DEXA scans can be less accurate in patients who are obese or who have a very small stature. A QCT bone density study is a volumetric study, and the study is not dependent on the patients body habitus. A QCT bone density is not affected by degenerative changes or surrounding calcifications. As this patient has small stature and has not tolerated several medications for osteoporosis, it was medically necessary to accurately determine the extent of her osteoporosis to determine the appropriate therapy. The QCT bone density scan was appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Synvisc One for medical treatment of his left knee pain.  Findings:  The physician reviewer found that although the patient was identified as having degenerative changes regarding his left knee, there was no documentation of a formal diagnosis of osteoarthritis. Additionally, the clinical documentation does not demonstrate that the patient has had a previous allergic reaction to Euflexxa or Orthovisc or was intolerant to either of the medications as an injection treatment prior to requesting the Synvisc One.  The clinical documentation does not demonstrate that the patient has been formally diagnosed with osteoarthritis to support the use of viscosupplementation with a Synvisc One injection at this time. Therefore, the medical necessity of the requested therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Robaxin 750 mg (three times/day; 30-day supply), (2) bupropion 150 mg (Wellbutrin-XL, three tablets/day, 30-day supply), (3) gabapentin 600 mg (three times/day, 30-day supply), (4) Norco 10/325 mg (30-day supply), (5) myelogram computed tomography (CT) scan, and (6) single-photon emission computed tomography (SPECT-CT) scan. McGhee and colleagues note that winged scapula is one potential underlying cause of shoulder pain and that history taking, physical examination, and imaging are needed for a correct diagnosis. Didesh and Tang note that the condition is painful and debilitating. Rustagi and colleagues note that in rare instances, winging and snapping of scapula may be caused by space-occupying lesion of the thoracic wall. The authors further note that while osteochondroma of scapula is rare, it is the most common neoplasm of scapula, and osteochondroma of ventral scapula may lead to pseudo-winging, snapping, and rib erosion on the same side. In this case, the requested CT scans would help identify a bony tumor.  In this clinical setting, given the patients worsening pain and declining function that inhibit participation in therapy, a multimodal pain treatment approach with a trial of multimodal analgesics is indicated to assess if the patient is able to obtain some functional relief. Therefore, (1) Robaxin 750 mg (three times/day; 30-day supply), (2) bupropion 150 mg (Wellbutrin-XL, three tablets/day, 30-day supply), (3) gabapentin 600 mg (three times/day, 30-day supply), (4) Norco 10/325 mg (30-day supply), (5) myelogram CT scan, and (6) SPECT-CT scan are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services and medications 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 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for the evaluation of her medical condition.  Findings:  Three physician reviewers found that due to the advantages tomosynthesis provides to radiologists interpreting mammograms, the American College of Radiology (ACR) has urged the technique be removed from the investigational category. The advantages of tomosynthesis are due to the tomographic nature of the technique allowing radiologists to separate dense glandular tissue from underlying mass/architectural distortion. There is sufficient literature to support an associated decrease in callbacks and increase in detection of small cancers when tomosynthesis is used as part of the screening process. This has been shown to be particularly valuable in patients with heterogeneously dense or extremely dense tissue. For these reasons, it is likely that the addition of tomosynthesis to the usual two-dimensional (2D) mammogram views was likely of more benefit to this patient than had the exam been done with 2D technique only.  Final Result: 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:   All three reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

 A 51-year-old female has requested coverage for past electrical stimulation (CPT 97032) provided for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that the patient has a history of urinary incontinence, hysterectomy and bladder suspension. The patient was referred to physical therapy and received therapy that included pelvic floor strengthening exercises and biofeedback. Modalities included in her therapy were soft tissue oscillation, laser and electrical stimulation.  All told,  electrical stimulation (CPT 97032) has not proven to be more beneficial than other more standard forms of therapy. As reported by Berghmans and colleagues, electrical stimulation has not been found to be superior to other forms of therapy. The authors noted that treatment with pelvic floor electrical stimulation did not increase effectiveness of a comprehensive behavioral program for women with stress incontinence. Overall, there is a lack of clinical data suggesting use of pelvic floor electrical stimulation is expected to result in an improved health outcome when compared with conventional therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation for the medication, Stelara 90 mg/mL subcutaneous injections to every four weeks. Current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has disease symptoms consistent with active disease while taking Stelara every eight weeks. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory testing results reported a low Stelara level of 2.0 ug/mL. Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, dosage escalation for the medication, Stelara 90 mg/mL subcutaneous injections to every four weeks, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for TMS services provided by Southern California TMS. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether TMS services that were received at Southern California TMS were medically necessary for the treatment of the patients medical condition. McDonald and colleagues reported repetitive transcranial magnetic stimulation (rTMS) as an important therapy for treatment resistant depression (TRD). Researchers noted that the U.S. Food and Drug Administration (FDA) approved TMS for treating major depressive disorder in patients who have not responded to prior antidepressant medications. TMS therapy should be considered in patients who present with a clinical diagnosis consistent with major depressive disorder for whom antidepressant medication has not provided a satisfactory clinical benefit, or for whom intolerance to medications precludes their use. For patients who experience a relapse after previously benefitting from an acute TMS course, medical evidence supports reintroduction of TMS until remission is re-achieved. In this case, the patient has previously demonstrated positive response to TMS. Medical evidence supports the services at issue in this clinical setting. Therefore, TMS services that were received at Southern California TMS were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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

The parent of a 15-year-old male enrollee has requested residential treatment services for treatment of the enrollees bipolar disorder, attention deficit/hyperactivity disorder and conduct disorder. Findings:  The physician reviewer found that given this patients behavior and symptoms, including the need for restraints, residential level of care was medically indicated for this patient.  He required 24-hour residential level of care during the dates of service at issue.  Residential treatment was required based upon American Academy of Child and Adolescent Psychiatry guidelines. All told, residential treatment services provided during the time period at issue were medically indicated for this patient.