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

A 45-year-old male enrollee requested a positron emission tomography (PET) scan for medical evaluation of his large cell lymphoma. Findings:  Two physician reviewers found that Terasawa and Nagai found that interim PET should at present not be regarded as an established procedure and it still remains as an unproven test for routine clinical practice. In the absence of a clinical indication for the requested diagnostic procedure, the requested PET scan is not likely to be more beneficial for evaluation of the patients diffuse large cell lymphoma than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested for bilateral core decompression with implantation of autogenous iliac crest bone graft for treatment of his bilateral hip avascular necrosis status post left core decompression.  Findings:  The physician reviewer found that the value of core decompression for treatment in early cases has been recognized for some time, and has been reported to be effective in 60% to 80% of cases at 5 to 10 years follow-up, as noted by Mont and colleagues. The addition of bone graft to increase structural support and provide a scaffold for bone and vascular growth is also well-recognized. The current medical evidence supports bilateral core decompression with implantation of autogenous iliac crest bone graft in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that There is sufficient support for the medical necessity for the services at issue in this clinical setting. Although the patient had no ideas of self-harm, and was euthymic, cooperative and sleeping well, service delivery in a less restrictive setting would have been inadequate and potentially unsafe at the time.  The records demonstrate that this patient remained symptomatic and had not consolidated the treatment gains necessary to succeed in an outpatient based program. The co-occurrence of major depression and anxiety is of particular relevance since it has been well established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, that anxiety ridden mood disorders are difficult to treat and in general have poorer outcomes.  Further, the patient had failed treatment in a lower level of care during the episode of illness.  She lived alone.  She was unable to work.  She was negotiating complex bereavement in context of problematic sibling dynamics, emotional dysregulation, self defeating personality traits and clinical depression.  According to the records provided, the patient remained actively engaged in treatment throughout the entire admission.  For example, she continued mindfulness and dialectical behavioral therapy groups, in addition to individual counseling.  She started a new antidepressant, bupropion.  She completed family therapy sessions.  Her mother was referred to National Alliance on Mental Illness (NAMI) for additional support. Aftercare services were established.The services provided were reasonably expected to improve her condition and prevent a more serious episode of illness. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether tongue radiofrequency rendered was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. The patient was diagnosed with chronic rhinosinusitis with nasal obstruction, macroglossia, and obstructive sleep apnea.  The enrollee underwent a partial glossectomy previously.  The enrollee continued to report no improvement in the quality of sleep or symptoms after the procedure. Two out of three medical experts found that per the American Academy of Otolaryngology Head and Neck Surgery (AAOHNS), patients with mild to severe obstructive sleep apnea (OSA) can be successfully treated with submucosal radiofrequency tongue base ablation. Radiofrequency ablation is clinically effective in reducing respiratory disturbance index levels and symptoms of sleepiness in patients with OSA syndrome when directed at the base of the tongue or as a multilevel procedure. Therefore, the tongue radiofrequency that was rendered was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. One out of three reviewers found that this patient has undergone multiple prior surgical procedures, including nasal reconstructive septoplasty, partial glossectomy, and sinus surgery. Currently, there is a lack of literature supporting that tongue based radiofrequency has clinically proven benefit to tighten the tongue after a prior partial glossectomy.Final Result: Two out of three of the reviewers determined that the requested test was 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 otolaryngology, 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for right ear otoplasty. In California, surgery is considered reconstructive (i.e., not cosmetic) if it is performed to approximate a normal appearance on an abnormal structure of the body caused by a congenital defect. Researchers found congenital ear deformities can produce significant social and psychological effects on an individual.  Both children and adults may suffer a damaged psyche secondary to outside ridicule and self-criticism from ears that are malformed. In this case, the patients ear condition constitutes an abnormal structure of the body resulting from a congenital defect. Otoplasty is being requested to correct this condition and approximate a normal appearance. It should also help alleviate the social distress the patient is experiencing as a result of their ear condition. Therefore, otoplasty is a medically necessary reconstructive procedure for this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology with a subspecialty certificate in plastic surgery of the head and neck, 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 Orthovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient reportedly obtained lasting benefit from viscosupplementation in the past. Furthermore, the patients remaining treatment options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Additionally, the provider does not consider the patient to be an ideal candidate for surgery. For these reasons, the requested Orthovisc injections of both knees are medically necessary for management of this patients osteoarthritis of both knees.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 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

The patients enrollee requested coverage for the Nutropin AQ Nuspin. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug administration approval for this indication is for non-growth hormone-deficient short stature and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. The patient had growth hormone administered in the past with documented benefits. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in pediatric endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vyvanse 30 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that Vyvanse is a central nervous system stimulant approved by the U.S. Food and Drug Administration for the treatment of ADHD. The compound is a prodrug of dextroamphetamine. After oral administration, lisdexamfetamine is rapidly absorbed and converted to dextroamphetamine, which is responsible for the drugs psychoactive properties. Amphetamines generate a clinical effect by inhibiting norepinephrine and dopamine reuptake into the presynaptic neuron and increasing release of these monoamines into the extraneuronal space of the prefrontal cortex. Stimulant medications, like lisdexamfetamine, are first-line therapies for ADHD. ADHD commonly presents in the primary care setting and is routinely treated with psychostimulants by primary care providers. Thus, the diagnosis and treatment of ADHD falls within the scope of primary care physicians. In this case, the documentation supporting the diagnosis of ADHD lacks an element of comprehensiveness such as a clinical rational or interpretative statement by the diagnosing provider supporting the justification of an initial diagnosis. Considering current practice standards and provisional diagnosis, to maintain patient centricity, continued treatment with Vyvanse 30 mg is medically necessary for a period of three months which would allow the patient opportunity to meet with a psychiatrist for a consultative and comprehensive evaluation.  Final Result: The reviewer determined that the requested medication for a duration of three months 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 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: A male enrollee has requested reimbursement for the residential treatment services provided for treatment of the enrollees alcohol use disorder and major depressive disorder. Findings:  The physician reviewer found that the records indicate that this patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential treatment center level of care. He was medically and psychiatrically stable. He was motivated and appeared to be working the program. He was cooperative and participating in his treatment plan. Although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting and the patient could have been stepped down to an ambulatory level of care. All told, the residential treatment services provided were not medically necessary for treatment of the patients medical 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 with sub-specialty certification in addiction 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 authorization and coverage for inferior turbinate outfracture. Findings:  The physician reviewer found that the submitted documentation does not support the requested procedure in this clinical setting. This patient has mild, but symptomatic, obstructive sleep apnea.  This patient is noted to have an arched narrow palate with resultant narrowing of the nasal airway. He is noted to have difficulty breathing through his nose while sleeping. While surgery may be the next treatment option for select patients who have failed CPAP therapy, in this patients case, the requested inferior turbinate outfracture, is not medically indicated. The documentation indicates that he had prior turbinate reduction and the examination notes state that there is no turbinate hypertrophy. Therefore, inferior turbinate outfracture, is not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for PET Scan and immunology assay for free light chain, kappa. The enrollee had IgG Kappa multiple myeloma diagnosed after a hip fracture. Findings:  the physician reviewer found that the biopsy showed kappa light chain with restricted plasma cell dyscrasia and a bone survey revealed a lesion in the right pubic bone. He was treated with chemotherapy. Subsequently, he underwent magnetic resonance imaging (MRI) and a positron emission tomography (PET) scan for treatment strategy planning and they were unchanged from a prior scan. Laboratory testing for immunoglobulin free light chains (kappa and lambda) was performed. According to the medical literature, the role of PET Scan in staging myeloma is not clear. Traditionally, myeloma was staged with IgG levels, bone survey and lab tests. While PET is very sensitive for metastases, it can be falsely positive and is not a good study for nodal staging. Only retrospective analyses are available. At the same time, another guideline indicates PET imaging is not for routine use in the management of myeloma patients. Although it may be useful in selected cases that warrant clarification of previous imaging findings, this approach should be made within a clinical trial. This enrollee had the PET Scan done for surveillance, not for relapsed or refractory multiple myeloma. However, regarding the immunology assay for free light chain, kappa, follow-up by immunoglobulin studies is well established and recommended by guidelines. Low levels of abnormal immunoglobins are often present and levels are typically determined through assays. Final Result: Three of the three reviewers determined the PET scan was not likely to bemore beneficial than any available standard therapy for treatment of the enrollees medical condition. Three of three reviewers determined the immunology assay for free light chain, kappa was likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.   Credentials/Qualifications: Three reviewers are board certified in medical oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Pennsaid 2%. Topical analgesics may be beneficial for the treatment of pain in a superficial location after trial and failure of oral medications including non-steroidal anti-inflammatory drugs (NSAIDs). In this case, there is no documentation of trial and failure of oral NSAIDs. The provider noted that the patient was treated with Voltaren gel without improvement. Additionally, there are no diagnostic reports, documentation of pain intensity, or physical examination of the musculoskeletal system to support the request for Pennsaid 2% solution. All told, the requested Pennsaid 2% is not medically necessary for treatment of this patient. 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 internal medicine with subspecialty certification in rheumatology 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 parent of an enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, 17 hours per month of supervision and one hour per week of parent training. Findings:  The physician reviewer found that a study indicated that intensive behavioral treatment is effective for children with autism. The study by Orinstein and colleagues found that children with autism receiving 25 hours per week of direct therapy were likely to have an optimal outcome than those receiving only 18 hours per week. In this case, the patient continues to have issue with non-compliance which have slightly increased. She has made progress with her current level of ABA services, however she still has not met her non-compliance goals. 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 pediatrics with sub-specialty certification in developmental-behavioral 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: Upheld

The patient is a 39-year-old female with avascular necrosis of the left hip. The patient has been followed by a pain management specialist due to the associated pain. The patients provider recommended changing the patients medication regimen from MS Contin to Percocet with continued use of Duragesic patch. The patient indicates discontinuation of MS Contin led to significant withdrawal symptoms and Percocet was ineffective. The patient is now seeking authorization and coverage for continued treatment with MS Contin, which has been denied by the Health Plan.The Health Plans denial should be upheld. The patients provider has recommended that MS Contin be discontinued. Without a second opinion from another pain management specialist, continuation of MS Contin is not medically appropriate. The Health Plan has recommended the patient be evaluated by another pain management clinic to determine a treatment plan for the patient. The alternative services recommended by the Health Plan are medically reasonable and appropriate. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.