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

The enrollees parent is requesting  reimbursement for residential treatment services. The enrollee has a history of major depressive disorder (MDD), post-traumatic stress disorder (PTSD), gender dysphoria, obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD), and Tourettes. The enrollee reported gender dysphoria with eventual identification as a male. Using the CALOCUS system, the total composite score correlates to Level 5. Residential care is appropriate for this enrollee. The literature supports a psychiatrist should determine the most appropriate level of care and that treatment for depression may occur in a variety of settings. The determination of an appropriate setting for treatment should include consideration of the enrollee's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a urology consultation. This patient presents with a history of recurrent epididymitis. The patients symptoms reportedly subsided after two courses of antibiotic therapy. The patient's diagnosis was established with physical examination and scrotal ultrasound. The patient has history of human immunodeficiency virus (HIV) which predisposes them to recurrent urinary tract infections and infections of the genitourinary tract including epididymitis. Therefore, it should be appropriate for this patient to be evaluated further for the resolution of epididymitis by an urologist. For these reasons, the requested urology consultation is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 urology 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 an eight-year-old male enrollee has requested a customized pediatric wheelchair for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the requested customized pediatric wheelchair is medically necessary for this particular patient as it is associated with significant medical benefits for a patient such as this patient. This patient has paraparesis and upper body weakness and needs forearm trays. In addition, pelvic straps, shoulder harnesses and safety belts are required to address his muscle spasticity. Furthermore, various seating support options (such as position back cushions, lateral trunk and hip supports) are medically necessary for this patient to promote spinal stability and respiratory/pulmonary function and prevent soft tissue (joint/muscle contractures). Finally, removable and swing away foot rests are medically necessary for safely transferring him to and from his wheelchair. All told, the medical literature demonstrates that there are long-term positive effects on children with cerebral palsy who have customized/adaptive seating and positioning option. Thus, the requested customized pediatric wheelchair is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Belsomra 10 mg for treatment of the enrollees insomnia.Findings:  The physician reviewer found that there is a lack of documentation that Belsomra is superior to other medications that are also U.S. Food and Drug Administration (FDA) approved for the treatment of insomnia including Zolpidem, Zolpidem extended release, Lunesta, and Sonata. This patients records do not document an adequate trial and failure, or contraindication to treatment with these standard first-line therapies. Moreover, Belsomra is not FDA approved for the treatment of PTSD. 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 sub-specialty certification in pulmonary 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: The patient has requested authorization and coverage for applied behavior analysis (ABA) therapy. Sakaluk and colleagues conducted a meta-analysis on the effectiveness of the most commonly used treatment modalities in treating a variety of psychological issues. Per the authors, cognitive behavior therapy (CBT) has strong support in the management of anxiety and depression. However, there is a lack of documented support for ABA for patients with adjustment disorder, anxiety, or depression. In addition, the request for ABA is not based on a thorough assessment of need and a treatment plan detailing the specific deficits to be addressed. Based on the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, the required components of a treatment authorization include behavior analytic assessment and a treatment plan detailing specific goals to be targeted during treatment. This patients records lack documentation of elements to support ABA therapy. Moreover, the requested ABA therapy fails to meet the medical necessity criteria outlined by Papatola and Lustig. According to Papatola and Lustig, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. This patient does not meet criteria (a), (b) and (c). The records do not support that the requested ABA services are medically necessary to meet the essential health needs of the patient, ABA services are not consistent with the diagnoses for which they are being requested, and there is a lack of guidelines supporting ABA for the treatment of adjustment disorder, anxiety, or depression. For these reasons, the requested ABA therapy is not medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).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 licensed B.C.B.A, board certified in psychology, 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 rituximab for treatment of the enrollees thrombotic thrombocytopenic purpura. Findings:  The physician reviewer found that the physician reviewer found there is support for the requested medication in this patients case. TTP is a part of a class of diseases referred to thrombotic microangiopathies where dysfunction of the arteriolar/capillary endothelium causes uncontrolled microvascular thromboses by von Willebrand factor and platelets. Clinically, it manifests with thrombocytopenia, microangiopathic hemolytic anemia, acute kidney injury, purpuric rash, and central nervous system symptoms such as delirium. Von Willebrand factor is a major required factor for platelet aggregation. A deficiency of ADAMTS13, a metalloprotease that cleaves von Willebrand factor, is diagnostic of thrombotic microangiopathy when it is present in the context of all the other clinical signs. Acquired inhibitors are similar to the more common ones against factor VIII and develop due to several underlying diseases, such as cancer, systemic lupus erythematosus, postpartum, or drug reaction. The inhibitors are an autoimmune response that must be treated using immunosuppressive medications, such as corticosteroids and cyclophosphamide. Intravenous immunoglobulin and rituximab also work to lower inhibitor levels. Although the use of rituximab in thrombotic microangiopathy is off-label, there is sufficient published data to support its medical necessity in this clinical setting. All told, rituximab is 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 certification in 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Orthovisc injection series in the left knee. 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 from organizations such as the American Academy of Orthopedic Surgeons 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 is status post left knee arthroscopy, and partial medial and lateral meniscectomies, and has a diagnosis of osteoarthritis of the left knee. The patient has undergone postoperative rehabilitation and is progressing with an exercise program. As the patient has tried physical therapy and nonsteroidal anti-inflammatory drugs without relief, the provider has recommended viscosupplementation. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series in the left knee are 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees representative has requested reimbursement for Guardant360 liquid biopsy gene assays. Molecular diagnostic studies in non-small cell lung cancer are considered within the standard of care based on current publications and guidelines. In addition, numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) strongly advises broader molecular profiling with the goal of identifying driver mutations for effective therapies, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is key for the improvement of care in patients with non-small cell lung cancer. Testing of lung cancer specimens for specific alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Integration of molecular genetic testing into the routine management of patients with stage IV non-small cell lung cancer demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy. This patient with metastatic lung cancer underwent Guardant360 liquid biopsies less than one year apart.  It is standard practice to reevaluate a molecular panel with recurrences to see if the patients tumor has developed any new actionable mutations. All told, the Guardant360 liquid biopsy gene assays were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Guardant360 liquid biopsy gene assays were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty 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: Medical Necessity
Decision: Overturned

The parent of a ten year-old female with chronic nasal congestion is requesting authorization of a septoplasty.  The patient has leftward deviation of the anterior portion of the nasal septum causing narrowing of the anterior portion of the left nasal cavity.  The patient has tried multiple allergy medications and topical steroid sprays without relief.Reviewers Findings:The reviewing physician found that the patient has tried and failed medical therapy, making the patient an appropriate candidate for surgical intervention. Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested surgical removal of teeth #5 and #20 (with intravenous sedation) for treatment of his medical condition. Findings:  The physician reviewer found that the patient has a history of radiation treatment with the field of radiation including his maxilla and mandible. He has now been diagnosed with cervical caries of teeth #5 and #20. Although this patient does not currently have an active diagnosis of osteoradionecrosis, he has a significant history of radiation therapy and has been referred to an oral surgeon for removal of teeth in the hope of preventing this condition. The submitted documentation does not clearly establish if endodontic treatment (root canal) of these teeth has been considered in order to avoid a surgical procedure in this patient. As such, the medical necessity of the proposed surgical extractions has not been established at this time. However, if documentation is provided indicating that the patient is not an appropriate candidate for treatment with root canal, then the patients request for extraction and sedation of teeth #5 and #20 should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested inflammatory bowel disease (IBD) serology 7 for the treatment of her irritable bowel syndrome. Findings:  The physician reviewer found that an IBD serology panel is recommended only as an adjunct to differentiate CD and UC in patients with a clinical diagnosis of IBD and non-diagnostic histology and radiologic findings. In accordance with the American College of Gastroenterology Practice Parameters Committee, pANCA and ASCA, Omp-C, `may be useful in the patient in whom all other clinical features do not allow a distinction between UC and CD.` Thus, this patient did not meet the recommended indications for the use of serologic IBD testing.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested Treximet (85mg-800mg), up to two tablets per day for treatment of her chronic migraine.  Findings:  The physician reviewer found that Treximet is a combination of sumatriptan and naproxen. The patient has expressed concern about taking Imitrex due to elevation in her blood pressure. However, the use of Treximet would be expected to raise the patients blood pressure if plain sumatriptan causes such an increase. Further, the records provided for review do not document blood pressure issues in the clinical notes. All told, Treximet is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A forty-seven year-old female with breast cancer that metastasized to the spine is requesting reimbursement for a vertebroplasty.  The patient underwent a number of procedures followed by radiation therapy, and subsequently experienced disease progression in the spine.Reviewers FindingsOne physician reviewer found that despite the promising early results, the overall efficacy of vertebroplasty is still unproven in the management of metastatic vertebral compression fractures.  This reviewer found that the Health Plan denial should be upheld.The other two physician reviewers found that the patient was an appropriate candidate for the vertebroplasty. The procedure is not experimental or investigational and was clinically indicated in this case.  These reviewers found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested occupational therapy for two hours per week, and speech therapy for one hour per week for treatment of the enrollees autism and cerebral palsy.  Findings:  The physician reviewer found that this patient has made definite, although slow progress, in both activities of daily living and speech. Both of the non-plan OT and ST providers report that the patient is achieving some of her projected goals. In cases in which an individual is continuing to demonstrate improvement, without achieving a plateau in either activities of daily living or speech, the medical communitys usual and customary practice would be to continue OT and ST in an autistic teenager. The medical literature supports both OT and ST in this population. Pfeiffer and colleagues reported on an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the unwanted mannerisms associated with autism. May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing OT sensory integration techniques for autistic children. Their conclusion, based on the meta-analysis, was that sensory integration was effective.With regard to speech therapy, most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers and Johnson). The report of the Speech and Language Association, states that all autistic children can benefit from speech therapy. This report emphasizes that age is not a barrier to speech therapy. Based upon the information set forth above, the patient is an appropriate candidate for occupational and speech therapy at the requested frequencies. All told, the requested OT for two hours per week, and ST for one hour per week is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested Singulair (montelukast) for treatment of her allergic rhinitis. Findings:  The physician reviewer found that the patient has a history of allergic rhinitis, hypothyroidism and hives and has failed oral antihistamines. Given that this patient also has a history of hives and hypothyroidism, it is medically reasonable and appropriate to use the montelukast to treat both disorders. There is documentation that the patient tolerates the medication with no side effects. It was noted that there is no documented history of hydroxyzine, a sedating class 1 antihistamine. This patient cannot tolerate the sedation caused by Benadryl and given that hydroxyzine is even more sedating, she will likely not tolerate it as well. As such, the request for Singulair (montelukast) is medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder.   Findings:  Three physician reviewers found that the data reviewed fail to indicate that the requested services are likely to be more beneficial than other available treatment alternatives.  Details of past trials of medications, such as dose, length, degree of compliance, tolerance, and degree of response, or lack thereof, have not been documented. Additionally, the American Psychiatric Association indicates that electroconvulsive therapy is the most effective treatment for depression.  The current research does not demonstrate the superiority of transcranial magnetic stimulation therapy over antidepressant medications. Thus, the requested transcranial magnetic stimulation therapy is not likely to be of greater benefit than other available treatment options in this patients case.