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

Nature of Statutory Criteria/Case Summary: A 39-year-old female enrollee has requested authorization and coverage for Epclusa tablets 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 3. Findings:  The physician reviewer found that according to joint guidelines issued by 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 life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for applied behavior analysis (ABA) services including 31 hours of 1:1 therapy per week, 12 hours per month of supervision, two hours per month of parent training, and 12 hours total of reassessment. Medical literature states that 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 patients provider lists 20 goals on the treatment plan and outline. Based on current guidelines, 14 of these goals are required to meet the essential health needs of the patient and directly address behavioral issues related to the patients autism. The other six goals are not medically necessary because there is no specific link between the goal and specific behavioral issues related to the patients diagnosis of autism. Based on this information, 70% of the goals meet medical necessity criteria. Therefore, ABA services including 22 hours of 1:1 therapy per week, 8.5 hours per month of supervision, two hours per month of parent training, and 12 hours total of reassessment, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision Dx melanoma gene expression profile test for evaluation of the enrollees malignant melanoma. Findings:  Three physician reviewers found that the Decision Dx melanoma assay was developed from profiles of ocular melanoma samples and it is not clear that cutaneous melanoma behaves in the same manner to support a similar outcome. In addition, the National Comprehensive Cancer Network (NCCN) diagnostic and treatment guidelines indicate that this type of genetic testing should not be used outside of a clinical trial. Overall, the Decision Dx melanoma assay is not considered standard of care or part of the work-up for patients with melanoma. Final Result: Three 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: All three physician reviewers are board certified in dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ketamine infusion for treatment of the enrollees complex regional pain syndrome (CRPS). Findings:  The physician reviewers found that There is a lack of medical literature supporting the requested service in this clinical setting. There is no high quality evidence available evaluating the efficacy of ketamine for CRPS and all manuscripts examined in this review were of moderate to low quality. Therefore, there is currently only weak evidence supporting the efficacy of ketamine for CRPS. There is also concern for possible toxicity with the use of ketamine infusion that needs to be further assessed.  Given the lack of support in the peer-reviewed literature, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  Different SpecialtiesOne reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested facet joint injections for treatment of her right hip and low back pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested facet joint injections. The patient has right hip pain and low back pain with significant abnormalities noted on her MRI. The patient also received epidural injections on the date indicated on the right side at right L2-3, L3-4, and L4-5 with positive result. Facet joint injections are not standard therapy in individuals such as this patient who have had previous surgical intervention and also continue to have multiple abnormalities demonstrated on imaging. Furthermore, the patient has responded positively to three level transforaminal epidural injections. Therefore, based on the medical records provided for review, the patients previous surgical history, significant abnormalities on the MRI and a positive response to three level transforaminal epidural injections, the requested facet joint injections at L3, L4, L5 and S1 are not medically necessary. In conclusion, the medical necessity of the requested therapy for treatment of this patients condition has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested vertebral axial decompression therapy for the treatment of her cervico-thoracic pain. Findings:  Three physician reviewers found that in the medical literature there is no good scientific evidence to support the use of vertebral axial decompression in the cervical spine over standard therapy. Furthermore, there is no indication from the medical records that the patient underwent and failed standard therapies for her medical condition. Vertebral axial decompression for this patients medical conditions is not generally accepted by the medical community as being a safe or an effective form of treatment and remains investigational and/or experimental.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for neck prolotherapy. A review of the medical literature reveals an absence of high quality studies demonstrating the safety and efficacy of prolotherapy for the treatment of chronic neck pain. A review by Chou and colleagues concluded that that the current evidence does not support prolotherapy as effective for the treatment of low back and radicular pain. Overall, the body of scientific evidence does not permit conclusions concerning the effect of prolotherapy on health outcomes for chronic neck or back pain. The records provided for review document that the patients treatment has included trigger point and prolotherapy injections. However, there is a lack of evidence that the patient has failed standard therapies for the treatment of chronic neck pain. Therefore, the requested neck prolotherapy is not medically necessary for treatment of this patient. 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 board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 40-year-old woman with a BMI of 39.9 and multiple comorbid conditions including sleep apnea and depression. The patient has undergone a psychiatric evaluation and obtained clearance, but the Health Plan has denied authorization for gastric bypass surgery indicating that the patient does not meet its criteria for weight loss surgery. With a BMI of 39.9 and documented comorbidities gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old male with a long-standing history of polysubstance abuse, involving principally marijuana but also more recent abuse of cocaine, including intravenous use. He first began using marijuana at age seven, introduced to such by his father amidst an otherwise exceedingly dysfunctional background, including his parents divorce, drug smuggling for his father, mother being a heavy marijuana smoker, and, at one point, being seduced by his grandmother who drank heavily and brought pornography into the home. Subsequently, the patient become a chronic user of marijuana (exact daily quantity unclear) but has also used a multitude of other drugs. Most recently, he was drinking daily and shooting a lot of cocaine, noted by his wife to have become very bizarre in the process. The patient noted a number of consequences to his drug use over the years, including several arrests involving alcohol and drugs, two DUIs, one possession charge, one resisting arrest charge, conflict with his wife, and stealing syringes from a physician when the physician left the room. His wife was also noted to smoke marijuana; the frequency of such is unclear.The patient was admitted to residential treatment on 1/22/05. When he was evaluated by a physician on 1/28/05, the physician noted it was difficult to elicit a clear and concise history from the patient because of his tangentiality. The patient was diagnosed with polysubstance dependence and personality disorder  not otherwise specified (primarily narcissistic).A request has been made for reimbursement for the substance abuse treatment services at issue. The Health Plan indicates the patient could have been treated at a less intensive level of care.While the documentation provided by the residential facility is quite topical in terms of treatments afforded the patient and concurrent treatment by a physician, the patients history is very telling for fairly egregious drug use. To the extent that just prior to his admission the patient had been shooting cocaine, having overdosed the week prior, and was using marijuana daily, he was clearly worsening. His wife noted him to be acting very bizarre and when he was seen by a physician some six days after his admission, he was so tangential and circumstantial as to make it difficult to elicit a clear and concise history. It appears the patient was also suffering from a concurrent substance induced mood disorder, not simply polysubstance dependence. Therefore, the morbidity of this patient was quite substantial and in the face of his most dysfunctional background, alongside tension in his marriage and his wife also smoking marijuana, he did not appear to have nearly enough support for sobriety if left in his usual setting. Rather, the patient required a physically separate space and program where he would not have access to drugs or alcohol (i.e., a residential program). Accordingly, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for arthroplasty of first carpometacarpal joint, right hand. This patient is being treated for osteoarthritis of right first carpometacarpal joint. The patients symptoms began over two years ago and are interfering with her ability to perform activities of daily living. However, there is a lack of detailed documentation regarding trial and failure of recent reasonable and comprehensive less invasive conservative care measures. The records document that previous treatment with injection therapy occurred in 2020 and 2021. Treatment with thumb spica brace and medications were not noted on the most recent examination. Moreover, the patients physical examination did not reveal significant deficits that support surgical interventions. There are limited large-scale, long-term references demonstrating the safety and efficacy of the requested right hand arthroplasty of first carpometacarpal joint in this clinical setting. Huang and colleagues performed a systematic review on the peer-reviewed medical literature evaluating thumb carpometacarpal joint total arthroplasty for osteoarthritis. The authors reported that, Overall, the published evidence does not show that total arthroplasty is better than trapeziectomy and its variants yet there is a higher complication rate. Kollig and colleagues discussed that aseptic loosening of the prosthesis is likely the major cause of the high failure rates reported for cemented and uncemented types of implants. The authors concluded that, joint replacement may be considered as a possible treatment option for advanced osteoarthritis of the thumb carpometacarpal joint, but it should not always be recommended because long-term results are inconsistent and similar functional outcomes have been reported for alternative surgical techniques, such as resection arthroplasty. All told, the requested arthroplasty of first carpometacarpal joint, right hand is not medically necessary for treatment of this patient. 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 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 enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three 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.  As noted by researchers, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Three 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:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX Reflux Management System. The U.S. Food Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. LINX is indicated for patients with medically refractory disease. In addition, on pH testing there was a weak to poor correlation between her symptoms and episodes of acid reflux. Given these findings, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 51-year-old female enrollee has requested removal and reimplantation of a new implant in the left breast, and reimplantation of a new implant in the right breast for the treatment of her right ruptured silicone implant. Findings:  The physician reviewer found that reconstructive surgery is defined as a procedure performed to correct or repair abnormal structures due to congenital defects, developmental anomalies, trauma, infection, tumors or disease in order to improve function and/or create a more normal appearance. The surgery must also result in more than minimal improvement in appearance to be considered reconstructive. In the case of this patient, the submitted documentation does not demonstrate the presence of an abnormal structure of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors or disease. The patients photographs do not document an abnormal appearance. There appears to have been minimal capsular contracture, and as such, evidence of an abnormal structure is not visible. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. With regard to the medical necessity of the proposed procedures, while the right breast implant rupture meets clinical indications for removal (and has in fact been authorized by the Health Plan), replacement of the right breast implant is not medically necessary from a functional standpoint. Replacement of the right breast implant would be for cosmetic purposes only. Furthermore, removal and replacement of the left breast implant does not meet medical necessity criteria for removal and replacement, as these procedures are not indicated to remedy a functional impairment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested hip surgery (surgical release of femoroacetabular impingement syndrome, also called FAIS) for treatment of her FAIS.  Findings:  Two physician reviewers found that the records indicate this patient presented with significant acetabular impingement associated with a labral tear. The peer-reviewed medical literature supports surgical release of FAIS in this patients clinical setting. Repair of the labral tear without osteoplasty would not be expected to provide this patient with a superior health outcome. In addition, significant impingement was noted during surgery that would have compromised labral repair. Acetabular osteoplasty was needed to eliminate impingement and allow labral repair to heal. Thus, the services at issue are supported in the medical literature as likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.