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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Lexapro for treatment of the enrollees depression and bipolar disorder. Findings:  The physician reviewer found that Escitalopram is a potent and highly selective serotonin reuptake inhibitor that acts by binding directly to the serotonin transporter. Escitalopram was first approved by the U.S. Food and Drug Administration (FDA) in 2002 for treatment of major depressive disorder, and a year later for generalized anxiety disorder. As noted by researchers, bioequivalence testing ensures that the generic product performs the same as its respective brand-name product. This standard applies to all generic drugs, whether immediate or controlled release. A particular compound associated with a specific brand name medication, or generic preparation, may be necessary for an individual patient in the instance of ineffectiveness or intolerance to one type of preparation. However, the brand name Lexapro is not supported for this patient as there is no evidence in the records that the generic medicine has been poorly tolerated or was inefficacious. This patient has been diagnosed with bipolar illness and is prescribed four antidepressants, in addition to an anxiolytic and mood stabilizer. Although medication adjustments may be indicated, the brand name medication Lexapro is not supported as medically necessary for treatment of the patients medical condition. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a mastectomy of the right breast for treatment of her medical condition. Findings: The physician reviewer found that unilateral mastectomy, considered to be prophylactic, may be appropriate in a patient in whom therapeutic mastectomy has previously been performed or is being contemplated for breast cancer.  Such women are at higher than normal risk for developing contralateral breast cancer.  However, when considering contralateral prophylactic mastectomy in a patient with cancer, it is important to recognize that many women overestimate their risk of developing a second cancer.  A detailed discussion of a patients risk of a contralateral breast cancer, the lack of impact of prophylactic mastectomy on mortality from the index cancer, and the significant benefit of endocrine therapy in reducing the risk of contralateral cancer should be included in the discussion of prophylactic mastectomy in this circumstance. This patient is not a candidate for endocrine therapy due to her estrogen receptor/progesterone receptor negative breast cancer. Mastectomy of the contralateral breast may be considered for risk reduction in patients at high risk for a contralateral breast cancer.  Additionally, mastectomy of the contralateral breast may be considered for patients in whom subsequent surveillance of the contralateral breast would be difficult.  This includes patients with clinically and mammographically dense breast tissue or diffuses indeterminate microcalcifications in the contralateral breast.  The requested services are medically appropriate in this patient with breast cancer and a mammogram interpreted as having heterogeneously dense to dense breast tissue with a nodular appearance.  Therefore, the requested mastectomy of the right breast is medically necessary for the treatment of this patient.  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 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: Upheld

An enrollee has requested authorization and coverage for anorectal manometry. The submitted documentation does not support that the requested services are medically necessary. Typical indications for anorectal manometry testing include fecal incontinence, constipation and to guide biofeedback therapy. In this case, the patient has a body odor that is felt to be originating from the anorectal area. At this time, there are no well-designed, established, randomized control trials that have proven the safety and efficacy of anorectal manometry for the requested indication. Evaluation for body odor that is felt to be related to the anorectal area is not an indication for anorectal manometry in the current, peer reviewed medical literature. Accordingly, the requested anorectal manometry is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat 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 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 53-year-old male enrollee has requested for proton beam radiation therapy (PBRT) for treatment of his prostate cancer. Findings:  The physician reviewer found that PBRT is not proven to be superior to external beam radiotherapy or brachytherapy as currently there are no randomized studies comparing treatment modalities for prostate cancer.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male has requested approval for 10 hours per week of applied behavioral analysis (ABA) therapy and 2 hours per week of supervision for treatment of his pervasive developmental disorder, not otherwise specified.   Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient has behaviors consistent with pervasive developmental disorder, not otherwise specified as he meets 7 of the 12 criteria for the diagnosis based upon the DSM-IV. ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorders (Granpeesheh, et al. and Sallows, et al.). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles. Studies have also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Sallows, et al.). The goals for older children often are to identify and remediate particular deficits such as the tantrums, poor peer relationships and social skills, and concerns for elopement and self-help exhibited by this patient. As such, the requested 10 hours per week of ABA therapy and 2 hours per week of supervision are clinically indicated and medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested for laparoscopic supracervical hysterectomy with or without removal of ovaries for treatment of her pelvic pain, uterine fibroids, dysfunctional uterine bleeding and dysmenorrhea. Findings:  The physician reviewer found that the records do not indicate when her endometrium was noted to be benign, since there were no specific records of such an evaluation.  Such an evaluation is medically necessary before consideration of hysterectomy.  As noted by the American College of Obstetrics and Gynecology, all women older than 40 years who present with suspected anovulatory uterine bleeding should be evaluated with endometrial assessment after pregnancy has been excluded.  They also note that adult women of reproductive age with menorrhagia, metrorrhagia or amenorrhea require evaluation for a specific cause. The laboratory assessment of these women should include a pregnancy test, a fasting serum prolactin level and determination of levels of thyroid stimulating hormone.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement for physical therapy sessions including the use of an AlterG anti-gravity treadmill. The medical literature does not support that physical therapy sessions that include the use of an AlterG anti-gravity treadmill are superior to traditional physical therapy. The literature cited in support of the patients request are limited to case studies that have a small sample size. A study that considered rehabilitation with anti-gravity treadmill after Achilles tendon surgery had roughly 16 patients. Their study found that the group of patients who used the specialized treadmill returned to ground running only a short time prior to those patients who had traditional physical therapy. The article suggested that this difference was not statistically significant. In this case, the patient underwent open reduction internal fixation of a navicular stress fracture and was advised to engage in physical therapy to provide intrinsic muscle strength, proprioception, gait/balance, and running conditioning. The orthopedic surgeon specifically recommended the use of a particular type of treadmill, the AlterG anti-gravity treadmill, which would allow the patient to run on the treadmill while removing a percentage of his body weight (anti-gravity). The medical literature, however, does not establish that the use of this anti-gravity treadmill is superior to traditional physical therapy. Accordingly, the physical therapy sessions including the use of an AlterG anti-gravity treadmill were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in podiatry 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

A 46-year-old female enrollee has requested antineoplastons (ANP) for treatment of her brain tumor.  Findings:  Three physician reviewers found that the requested antineoplastons treatment is not likely to be more effective for this patient than other available treatment options. Standard treatment in this setting consists of a combination of surgery, radiation, and chemotherapy (National Comprehensive Cancer Network Guidelines). While these modalities are not curative, patients can expect some palliation of symptoms, and a modest prolongation in survival. Antineoplastons treatment has not been shown in high quality clinical trials to be effective in the treatment of any type of cancer. Treatment with antineoplastons remains of unproven benefit and is not likely to be more beneficial for this patient than standard management.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 57-year-old female diagnosed with chronic hepatitis C genotype 3. Laboratory results revealed a viral load of 933,310 IU/mL. A FibroScan showed liver stiffness of 6.1 kPa, consistent with F0-F1 fibrosis. The provider noted the patient is treatment naive. At issue in this case is whether Mavyret for eight weeks is medically necessary for the treatment of the patients medical condition. According to the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The AASLD/IDSA guidelines recommend that all patients should be treated, regardless of fibrosis stage and non-cirrhotic treatment-naive genotype 3 patients should be treated with Mavyret for eight weeks. The ENDURANCE-3 trial showed a 95% cure rate with eight or 12 weeks of treatment with Mavyret and a low relapse rate in treatment naive, non-cirrhotic patients with chronic hepatitis C genotype three infection. Further, the AASLD/IDSA guidelines report reduced survival rates with delayed treatment. Therefore, Mavyret for eight weeks is medically necessary for the 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 subspecialty 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

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Therefore, Harvoni should be approved for 12 weeks in this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for Jaw Reconstruction Surgery-Reconstruct Full Maxilla. According to the enrollees medical record, he sustained an injury resulting in a broken jaw and loss of teeth. He had open reduction internal fixation surgery to fix his broken jaw. His physician states he has multiple issues directly as a result, including malnutrition, digestive problems, mood disorders, limited social activity, and speech problems. He has been diagnosed with moderate atrophy of the maxilla, hyperactive gag reflex, and myalgia. This enrollee sustained maxillofacial trauma. Due to the trauma, he lost his maxillary dentition, is currently edentulous in the maxilla, and has presumably been functioning with a full denture maxillary removable prosthesis since that time. The recommendation was for maxillary bone grafting and implants related surgical services to restore normal anatomy, function and esthetics.  It is evident based on the radiographic CT images that the enrollee exhibits a maxillary defect and edentulism in the maxilla.  Further, it is documented that function has been impaired since the time of initial trauma.  Despite documentation that indicates that the trauma was many years prior, the trauma was the proximate cause of the loss of function and directly resulted in the current condition and functional impairment. Given the clinical and radiographic findings, reconstruction of the maxilla and implant placement is indicated to restore function. Lastly, the services to be performed meet the expanded concept of medically necessary reconstructive criteria as defined by California law as follows: The requested jaw reconstruction surgery (reconstruct full maxilla) is medically necessary to treat the enrollees condition. The alleged abnormality does constitute an abnormal structure of the body. The abnormal structure of the body is caused by Trauma. The requested surgery is performed to improve function and create a normal appearance to the extent possible. The surgery does provide more than a minimal improvement in the appearance of the enrollee. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The reviewer is board certified in Oral and Maxillofacial 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 13-year-old female enrollee has requested knee arthroscopy with osteochondral allograft transplant (OATS) procedure for treatment of the enrollees osteochondritis dissecans lesion.  Findings:  Three physician reviewers found that it is in the patients best interest to proceed with the providers recommendation for the OATS procedure as further treatment for the patients condition of osteochondritis dissecans lesion of the knee. This patient has already undergone a first-line treatment option of surgical intervention consisting of drilling the lesion (Wall, et al). This was unsuccessful and the provider has noted an area of necrotic bone beneath the lesion. This poorly vascularized necrotic bone is not capable of supporting fibrocartilaginous ingrowth. Both the patients continued symptoms and the identification of poorly vascularized bone provide a reasonable indication for the use of the OATS procedure. Unless bone and cartilage plugs are utilized, the underlying poorly vascularized bone cannot be expected to support a stable solution to the osteochondritis. Miniaci and Tytherleigh-Strong used autogenous osteochondral grafting rather than allograft and demonstrated both clinical results and MRI evaluation evidence of significant healing. Given the peer-reviewed medical literature supporting the use of osteochondral transplant, either allograft or autogenous, the requested procedure is considered appropriate and likely to be more beneficial than standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a compound of levofloxacin and betamethasone. The Health Plan has denied this request indicating that the requested compounded medication is considered investigational for treatment of the enrollees chronic maxillary sinusitis.Findings: Three physician reviewers found that the record fails to establish the superior effectiveness of the requested compounded medication. This patients examination and computed tomography scan were non-diagnostic for chronic sinusitis. Per the records, there was resolution of the signs of disease. Based on the literature, nasal irrigation with topical medications is not supported as a primary treatment for chronic sinusitis. Therefore, the requested compound of levofloxacin and betamethasone is not likely to be of greater benefit than other treatment alternatives.Final Result: The reviewers determined that the requested compounded medication is 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 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a magnetic resonance imaging of the breast for evaluation of her medical condition. Findings:  Two physician reviewers found the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. The patient was diagnosed with Hodgkin lymphoma, mixed cellularity type. A metastatic work-up was negative and the patient was treated with chemotherapy and radiation. There is a lack of peer-reviewed literature that supports a breast MRI for this patient with normal mammogram and normal breast ultrasound. Also, the medical records fail to indicate that this patient has a lifetime risk of breast cancer that is 20-25% or greater. The patient has no suspicious breast lesions on mammography, ultrasound or physical exam. Thus, the request for MRI of the breast is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health guidelines for weight loss surgery. She has a BMI of 64, and the pathophysiology and the surgical outcome of this patient population is very well-defined. This patient needs to get down to a weight of 189 pounds for her BMI to be 30. This represents a weight loss of 222 pounds. The best outcome for this patient with the Roux-en-Y procedure would be a weight loss of 144 pounds (65% of 222 pounds). At 267 pounds, she would still be morbidly obese with a BMI of 42. From an outcome point of view, the duodenal switch procedure achieves superior results in this patient population. The requested duodenal switch operation will likely have a better outcome for weight loss and result in the resolution of this patients co-morbid conditions. Duodenal switch bariatric surgery is medically indicated for treatment of this patient.