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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Corrective flap reconstruction surgery for the neck. The researcher noted that in correction of the web neck the lateral approach associated with an advanced flap and a Z-plasty is an effective technique for correction of this neck deformity. The researcher and colleagues noted that, the choice of a surgical technique depends on the size of the skin folds, location of the hairline and the presence of bands of connective tissue. The lateral approach with a shift of glabrous skin flap to the back allows for effective reduction of the webbed neck, excision of bands of connective tissue and correction of the low hairline on the side of the neck. Z-plasty enables an adequate extension of scars and improves the contour of the neck. The decision for the surgical approach with Z-plasty is supported by current peer-reviewed medical literature. Z-plasty scars on the neck can become wide and hypertrophic, and treatment of the scars by nonsurgical modalities or by surgical revision is common. The timing of scar maturation is such that surgical scar revision is generally delayed for at least six months to allow maturation of wound healing. This patient underwent neck scar revision following surgery. The requested surgery is not medically necessary for the patients medical condition given the time that has elapsed since the recent revision procedure. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Neck webbing is an abnormal structure of the body caused by the congenital defect of Noonan syndrome. Surgical revision performed would not improve function or create a normal appearance, to the extent possible. Revisionary surgery before adequate wound maturation is likely to heal incorrectly. Another corrective flap procedure would be premature. Moreover, the requested procedure is not expected to provide a more than minimal improvement in the patients appearance. Final Result: The reviewer determined that the requested services are not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Overturned

A 61-year-old male enrollee has requested right L3-4 microdecompressive lumbar laminectomy, removal of the lesion (tumor versus cyst) for decompression, provocative lumbar discogram and epidural for the treatment of his lumbar pain. Findings:  The physician reviewer found that of the services at issue, removal of the lesion for decompression and the right L3-4 microdecompressive lumbar laminectomy were medically necessary, but the provocative lumbar discogram and the epidural were not medically necessary. The excision of the synovial cyst through a technique of open micro-laminectomy with operating microscope was appropriate and indicated. The cystic lesion needed to be addressed surgically. The pathology report ruled out tumor. Although the pathology report did not confirm synovial cyst lining, the MRI diagnosis and clinical diagnosis demonstrate that the cyst was clinically significant in this patients pain experience. The microdecompressive lumbar laminectomy performed by minimally invasive technique is controversial as a surgical approach, particularly when combined with the excision of the L3-4 extradural spinal perineural cyst. In this case, the MRI studies documented erosive changes in the lamina. As an ancillary procedure to the primary procedure of excision of the perineural cyst, the microdecompressive lumbar laminectomy was medically appropriate in this particular setting and appears to have been efficacious in relieving the patients pain. The discogram and the epidural did not contribute to the surgical treatment provided. There was no indication for these procedures based on the information provided. As such, medical necessity for the discogram and epidural has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: The 3 reviewers determined that the service at issue 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 reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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: Urgent Care
Decision: Overturned

A 65-year-old male enrollee requested services required on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patients decision to seek care was consistent with the actions of a prudent layperson in this setting. The record demonstrates that the patient required emergent care for urinary retention.   Although travel with an indwelling catheter would not have been prohibited, one would not expect a layperson to understand that an emergent/urgent issue did not exist, particularly since the patient had recently required urethrocystoscopy to reinsert the catheter after it was removed inadvertently.  In light of these circumstances, the services  meet prudent layperson criteria for emergent care/urgently needed services.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested neurologic music therapy for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. Researchers performed a review to assess the effects of music therapy for individuals with Autism Spectrum Disorder (ASD). The authors concluded The findings of this updated review provide evidence that music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. Furthermore, in secondary outcome areas, music therapy may contribute to increasing social adaptation skills in children with ASD and to promoting the quality of parent-child relationships. In addition, other researchers, in regards to treatments for ASD, state that the most promising therapies recommended are applied behavior analysis, parent-implemented training, melatonin supplements to improve sleep, supplements to correct deficiencies, and music therapy. Given the support in peer-reviewed literature, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in pediatrics and neurodevelopmental behavioral pediatrics and is actively practicing.  One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is 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

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the blood test (advanced lipoprotein testing) for evaluation of the enrollees medical condition. Findings:  The 3 physician reviewers found that there is adequate evidence to support the benefits of early diagnosis and treatment of hypercholesterolemia. However, the role in advanced lipid panel testing including laboratory testing, which may provide a more comprehensive assessment of dyslipidemia and cardiovascular risk than standard lipid panel measurements, remains controversial. Although increasing levels of low density lipoprotein (LDL) cholesterol and non-high density lipoprotein (HDL) cholesterol are associated with an increased risk of atherosclerotic cardiovascular disease, there is little data to support the need for advanced lipid panel testing in the general population. Given this patients LDL cholesterol, aggressive therapy is indicated regardless of any potential results from advanced lipid panel testing. Thus, the blood test (advanced lipoprotein testing) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: An enrollee has requested reimbursement for the Foundation One gene testing performed.  Findings:  The physician reviewer found that The Foundation One assay is a molecular assay that explores the mutations of an individual patients cancer cells. Currently, there is a lack of convincing evidence that the assay yields results that are reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling which have not demonstrated the efficacy of these analyses . West noted that research is ongoing and there are serious limitations of the available studies. A randomized trial  did not report significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Given these findings, the Foundation One gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:Physician reviewers 1, 2 & 3are  board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa and ribavirin for a duration of 24 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, no data is available for retreatment of Sovaldi and Daklinza failures in genotype 3 patients.  Epclusa/ribavirin for 24 weeks may be considered for those who require immediate retreatment, although no support for immediate retreatment, such as cirrhosis, is provided in this case. The guidelines state that the only available data is in patients who have failed Epclusa.  The guidelines otherwise recommend deferral of therapy in anticipation of future regimens, stating Given the limited data and marginal efficacy, genotype 3 patients who have failed an NS5A inhibitor and do not require urgent retreatment should have their retreatment deferred in anticipation of future regimens with improved activity in genotype 3 and against resistant variants.  Final Result: The reviewer determined that the requested medication regimen 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 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

The parent of 6-year-old male enrollee has requested speech therapy three times per week for the treatment of the enrollees verbal apraxia. Findings:  The physician reviewer found that the medical literature supports the use and medical necessity of speech and language therapy for verbal apraxia. However, there are no studies concerning the frequency of therapy. Because this patient has shown significant documented improvements with the frequency of therapy he has been receiving, it is reasonable and medically appropriate to continue this regimen, with timely evaluations (i.e., every three months) to document progress.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast examination.  Findings: Two physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only. Thus, the digital tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of three reviewers determined that the diagnostic procedure at issue 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: All three physician reviewers are board certified in diagnostic radiology 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 52-year-old male enrollee has requested Lyrica for the treatment of his polyneuropathy. Findings:  Two physician reviewers found that Lyrica has been beneficial for this patient. Lyrica is medically appropriate for the treatment of painful diabetic neuropathy. Management of neuropathic pain is usually a clinical extension of what is learned in clinical trials with well-studied neuropathy pain, typically diabetic in origin. There is no evidence that non-diabetic neuropathy pain responds differently than pain from diabetic neuropathy. There is evidence that supports the use of Lyrica in cases with non-diabetic neuropathic pain, including postherpetic neuralgia and fibromyalgia. Lyrica should be approved for this patient. He has already failed gabapentin, and he has had successful response to Lyrica.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a seven-year-old male has requested past and future coverage for neurofeedback and QEEG evaluation for treatment of autism and attention deficit hyperactivity disorder (ADHD).  Findings:  Two physician reviewers found that the patient presents with a history of autism and attention deficit hyperactivity disorder (ADHD). One provider states that the patient has experienced clinical improvement since starting treatment with neurofeedback. The patient has received 45 sessions of neurofeedback focusing on increasing cortical stability and connectivity since a date at issue two years ago. Per the provider, the patient has shown increased focus and ability to attend, increased expressive and receptive language skills, improved emotional stability, as well as decreased response latency when responding to questions, improved eye contact, and better interaction with family members and peers. The patient has also shown increased awareness of his surroundings by showing interest in other people and fewer tantrums. Holtmann and colleagues stated that, The existing evidence does not support the use of neurofeedback in the treatment of ASD. Studies with outcomes in favor of neurofeedback might be showing an improvement in comorbid attention-deficit-hyperactivity disorder symptoms rather than a true improvement in core ASD symptoms. Thompson and colleagues summarized data from a review of neurofeedback training with 150 clients with Aspergers syndrome and nine clients with ASD. A positive outcome of decreased symptoms of Aspergers and ADHD, including a decrease in difficulties with attention, anxiety, and social functioning, plus improved academic and intellectual functioning, provide preliminary support for the use of neurofeedback. However, these results are preliminary and not supported by properly designed double blind crossover studies. Further, there is a paucity of data supporting improved outcomes with neurofeedback in the treatment of ADHD. Consistent with these findings, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox and combination therapy with Botox and Aimovig. The current medical evidence supports Botox in this clinical setting. This patient has a history of chronic migraine headaches. Botox is an appropriate treatment for migraine prophylaxis in this patients case. The medical records provided for review indicated that the patient has been receiving Botox injections for migraine prophylaxis, with documented therapeutic efficacy. The continued use of Botox as a prophylactic therapy is consistent with the generally accepted standards of practice. Therefore, Botox is medically necessary for the treatment of this patient.The submitted documentation does not support the medical necessity of combination therapy with Botox and Aimovig. There is a paucity of literature evaluating the use of Aimovig in patients who are concurrently receiving Botox injections. Trials of Aimovig evaluated patients who had not receive Botox for a few months prior to the start of therapy. A study found that there may be a role for the use of Aimovig in combination with oral prophylactic therapies, the position statement did not discuss the use of multiple injectable agents. Therefore, combination therapy with Botox and Aimovig is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the requested medications 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 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.