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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for esomeprazole magnesium DR 40 mg capsule.Researchers state that GERD is at least partially caused by mechanical defects in esophageal motility. According to researchers, since proton pump inhibitors do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is likely to be needed to maintain remission. Moreover, medical literature indicate that insufficient acid suppression can result in complications of GERD, such as persistent erosive esophagitis, esophageal stricture, esophageal ring, and Barretts esophagus. Multiple studies show superior healing of erosive esophagitis with 40 mg daily dosing of proton pump inhibitor rather than 20 mg. Comparison of proton pump inhibitors, including rabeprazole, omeprazole, lansoprazole, and pantoprazole, has found no difference in the control and healing of gastroesophageal reflux disease. In this case, the patient has had GERD symptoms requiring treatment, and endoscopic biopsies revealed esophagitis. Records indicate that the patient did not have sufficient control with multiple proton pump inhibitors (pantoprazole, omeprazole, lansoprazole, and Dexilant). Although the formulary alternative rabeprazole has not been attempted, it is unlikely to be effective after failure of multiple other proton pump inhibitors. Alternatively, esomeprazole 40 mg daily has been effective. Therefore, esomeprazole magnesium DR 40 mg capsule is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A thirty-seven year-old male who had polysubstance abuse, sexual disorder/fetishism and personality disorder is requesting reimbursement for inpatient rehabilitation services.Reviewers Findings:  The reviewing physician found that the patient did not meet established criteria for admission to an acute inpatient drug rehabilitation program.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upgraded hearing aids. Hearing loss is the most common form of sensory impairment and hearing aids are a first-line of audiological intervention for many patients hearing loss with conditions that are improved with hearing aids. Age-related hearing loss is a multifactorial condition that affects more than one-third of the aging population. When left untreated, hearing loss can increase the risk of cognitive decline, dementia, social isolation, depression, and falls. This patient has mild to severe sensorineural hearing loss on the right and moderate to profound hearing loss on the left. This patients hearing loss documented by audiograms and is noted to have progressed. She has used hearing aids and would benefit from improved amplification. Given these findings, the requested upgraded hearing aids are medically necessary for this patient.Final Result: The reviewer determined that the requested equipment 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pembrolizumab and paclitaxel. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested medications in this clinical setting. Second-line chemotherapy for squamous cell non-small cell lung cancer often includes paclitaxel chemotherapy. There is increasing interest in combining chemotherapy with immunotherapy drugs, especially pembrolizumab. A recent study demonstrated that adding pembrolizumab to chemotherapy increased progression-free survival and overall survival. Therefore, pembrolizumab and paclitaxel are likely to be more efficacious than other available treatment options. Final Result: The reviewers determined that the requested medications 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: Physician reviewers 1, 2 and 3 are 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

A male enrollee requested a powered mobility scooter for medical treatment of the enrollee, who has been diagnosed with multiple sclerosis.  Findings:  The physician reviewer found that there are no indications in the records that the patients mobility related activities of daily living could not be accomplished with a manual wheelchair.  Physical activity is generally encouraged regardless of underlying health conditions that may exist, including multiple sclerosis.  Exercise has been shown to improve fatigue, mobility and quality of life in the setting of multiple sclerosis.  The use of a manual wheelchair would promote physical activity while accomplishing mobility related activities of daily living.  All told, the requested powered mobility scooter is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested AlloDerm for the treatment of her condition. Findings:  Two physician reviewers found that the use of AlloDerm is medically reasonable and appropriate in this case. It should be noted that AlloDerm is utilized in breast reconstruction with widespread usage.  Review of the above cited references indicates the usage of AlloDerm is not investigational and has become a standard of care.  Based on the scientific evidence available to date, the use of AlloDerm for this patients breast reconstruction is likely to improve the outcome of her breast reconstruction and therefore AlloDerm should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested for Tracleer for treatment of his idiopathic pulmonary fibrosis.   Findings:  Three physician reviewers found that the medical literature has not proven Tracleer to be effective in the management of IPF aside from having a role in the treatment of pulmonary hypertension. In the absence of pulmonary hypertension, there is no known benefit from Tracleer in the care of patients with isolated IPF without pulmonary vascular disease. Treatment aimed at pulmonary fibrosis usually involves the use of corticosteroids, immunosuppressive treatment, or a combination of these therapies. There is inadequate data to suggest the use of Tracleer is as good as, or better than, conventional therapies in the care of this patients IPF. While the patients force velocity capacity (FVC) and diffusion lung capacity (DLCO) are encouraging, there is insufficient literature demonstrating that his maintenance is attributable to Tracleer.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested electromagnetic navigation bronchoscopy (ENB) for an evaluation of his lungs. Findings:  The physician reviewer found that this patient is at high-risk for any procedure, whether it be a lung biopsy as one physician has apparently suggested or the electromagnetic navigation bronchoscopy (ENB) which another physician has recommended. This patient has already had a pneumothorax with a CT-guided biopsy. An ENB carries the risks of both pneumothorax and the chance that it too would be a non-diagnostic procedure. Thus, the potential clinical value of an ENB in this setting is outweighed by the risk this procedure poses to the patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six year-old male diagnosed with  developmental coordination disorder, ADHD, and disorder of written expression is requesting authorization for occupational therapy.  The patient has received a number of on-going occupational therapy sessions for these disorders.  Reviewers Findings:The reviewing physician found that the literature and the clinical record do not support the medical appropriateness of on-going occupational therapy sessions.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: This is a patient with bilateral primary osteoarthritis (wear and tear of the cushion between the bones) of the knees. The patient experiences bilateral knee pain and swelling. The provider requested bilateral hyaluronan injections for bilateral knee osteoarthritis. The patient has had both hyaluronan and corticosteroid bilateral knee injections in 2017-2019. The provider reports that the patient experiences better pain relief and increased activity level with the hyaluronan injections rather than the corticosteroid injections. During several visits, the provider documented the patients positive results to the injections. 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 orthopedic surgery and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for speech therapy services twice per week. The enrollee has developmental delay, speech delay, expressive language delay, and dyslexia. He is followed by a developmental-behavioral pediatrician and has been receiving speech therapy services since he was two and a half years old. The physician recommended speech therapy services for 50 minutes per session, at a frequency of two times per week. The enrollees mother reports her son is still showing articulation problems and problems composing sentences. She reports he has problems associating with other children because of his speech problems. Records show the enrollee performed poorly on standardized testing before starting speech therapy. This enrollee has received speech therapy for seven years. Each evaluation/evaluator has used a different standardized test, and it is therefore nearly impossible to assess accurately his response to treatment. Additionally, he continues to demonstrate variable degrees of deficits in various aspects of his speech and language. This is a poor response to intervention. Children who catch up to their peers do so by age seven. Deficits remaining after that time, as seen in this enrollee, are disorders, which are unlikely to resolve.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home oxygen for treatment of the enrollees obstructive sleep apnea (OSA) and hypoxemia. Findings:  The physician reviewer found that the records indicate that this patients OSA has been treated with CPAP. There is no oximetry on CPAP demonstrating hypoxia. Also, there is no documentation of a portable O2 system and the patients chest was noted to be clear on room air during multiple office visits. She does not have a history of smoking, chronic obstructive pulmonary disease (COPD), or interstitial lung disease. The right to left shunt was calculated as 3.6% but the most recent O2 saturation on room air was 97%. Overall, she does not meet the criteria of persistent O2 saturation of 88% or lower and her OSA has been treated with CPAP. All told, the requested home oxygen is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male has requested approval for an increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) for treatment of his chronic pain and depression.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantities in this patients case.  He has a known chronic pain condition and is on treatment with multiple medications, including narcotics.  Sources of chronic pain include neuropathic pain, visceral pain, and musculoskeletal pain.  Per the current medical evidence, treatment approaches can include combinations of medical therapy, behavioral intervention, interventional therapies, and rehabilitative interventions.  The current medical research indicates that treatment with narcotic analgesics for a period of greater than two weeks does not result in more favorable pain control than the use of non-steroidal anti-inflammatories or acetaminophen. Many studies have documented the high degree of comorbidity between depression and chronic pain, and there is evidence that the incidence of depression among patients with chronic pain is higher than for other chronic illnesses.  Per the medical documentation, the patient has a signed Controlled Substance Contract with his provider.  The records indicate that the patient tested positive for codeine and morphine, and these medications were not prescribed by the treating provider.  This constitutes a breach in his signed Controlled Substance Contract.  The current medical evidence does not support the requested increase in medications in this clinical setting.  All told, the requested increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 21-year-old female has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of depression and substance use.  Her symptom complex includes a two-year history of depressed mood with poor energy, decreased concentration, and erratic sleep cycle.  The patient has received individual psychotherapy.  Her prior medications included Prozac, Zoloft, Lexapro, Paxil, Remeron, Wellbutrin, Abilify, and Seroquel.  Psychopharmacology has not achieved remission.  The patient has requested coverage for transcranial magnetic stimulation.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.In this patients case, transcranial magnetic stimulation is not likely to be of greater benefit than other available treatment alternatives.  The documentation from 2011 describes the therapy as cognitive/behavioral therapy.  However, the notes do not describe the systematic application of this structured therapy, or any other evidence-based psychotherapy proven to be helpful in the treatment of depression.  Further, there is no follow-up discussion regarding the pursuit of more intensive treatment settings, such as intensive outpatient, partial hospitalization, or residential programming.  Finally, the specifics of psychotropic medication management strategies, including timing related to symptoms, adherence of treatment, relevant situational factors, and possible co-ingestion of alcohol or others substances, were not provided.  Thus, the superior effectiveness of transcranial magnetic stimulation has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous glucose monitor and disposable sensors. Salehi and colleagues note that hypoglycemia is a frequent complication occurring after bariatric and other forms of upper gastrointestinal surgery, posing severe health risks. The U.S. Food and Drug Administration (FDA) notes that CGM devices record blood sugar levels at repeated intervals throughout the day and night, detecting episodes of hyperglycemia and hypoglycemia, facilitating acute and long-term therapy adjustments. Given that the patient is status post gastric bypass surgery and is experiencing related hypoglycemia, the requested equipment is medically indicated. Therefore, CGM and disposable sensors are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided for treatment of an emergency medical condition.Findings: The physician reviewer found that At issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The urgent care services provided were not necessary for treatment of an emergency medical condition. In this case, the patient presented to an urgent care facility with reports of having a rash for the past three months. He denied any chest pain, difficulty breathing, or sore throat. The patients airway was patent. His lungs were clear. The patient also reported night sweats with pain at a prior site of a leg osteomyelitis. He denied fever. His vital signs were normal. His leg was not tender or erythematous. X-rays were consistent with old bone scar. Laboratory testing was unrevealing. The patients symptoms were not sudden or acute. He was not experiencing any airway compromise. There were no signs of acute infectious illness or sepsis. This patients symptoms were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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.