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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for oxycodone and morphine. The Guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Guidelines also state that continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of evidence of the patients progress toward treatment objectives, and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.  This patient has chronic pain. The current medical evidence does not support the requested medications in this clinical setting. The risks of combining opioid therapy with sedatives and cannabis outweigh any potential benefit of chronic opioid therapy. Therefore, oxycodone and morphine are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 sub-specialty certification in pain 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

A thirty-one year-old female who underwent right knee surgery is requesting reimbursement for electronic controlled thermal therapy device and an ambulatory infusion pump.  Reviewers Findings:The reviewing physician found that both the electronic controlled thermal unit and an ambulatory infusion pump could not be recommended as medically necessary for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 38-year-old female with active Crohns disease. She has been treated with 6-MP, Azulfidine and Remicade. Although she responded positively to Remicade, she apparently experienced a hypersensitivity reaction and continued treatment is contraindicated. The patients provider has requested authorization for treatment with Humira. The Health Plan denied the request citing a lack of medical necessity.The patient continues to have flares of her Crohns disease despite treatment with all of the commonly prescribed medications. Although Humira has not been approved by the FDA for the treatment of Crohns disease, it has been used in multiple clinical trials with good results. Treatment with Humira is a reasonable alternative to total colectomy, and the patients clinical history suggests that it will be effective.  Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision gastric bypass with lap band removal for sleeve gastrectomy for treatment of her complications related to lap band surgery. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for lap band removal is medically necessary. This patient has negative symptoms related to the lap band. Although there are no anatomic complications noted, intolerance is a medically necessary indication for lap band removal as it is associated with increased risk of secondary complications such as prolapse, obstruction, erosion. However, the request for conversion to sleeve gastrectomy is not medically necessary for this patient. The U.S. Food and Drug Administration (FDA) approved the lap band for use in patients with low BMI of 30-35 kg/m2 and these are not the standard guidelines for patient selection for the sleeve gastrectomy, which require a BMI of 40 kg/m2 or 35 kg/m2 with serious co-morbid conditions such as sleep apnea, diabetes or hypertension. The documentation submitted for review does not show that the patient has any of these co-morbid conditions. In addition, an updated multidisciplinary evaluation that includes dietary, surgical, and psychological assessments is indicated. Final Result: The reviewer determined that a portion of the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL pen injectors. Findings:  The physician reviewer found that records provided for review document that this patient has a long history of atopic dermatitis that has failed to substantially respond to treatment with Vaseline, mometasone or tacrolimus. The patients provider has recommended treatment with Dupixent. Simpson and colleagues noted that, Although most patients with atopic dermatitis (AD) are effectively managed with topical medication, a significant minority require systemic therapy. Once all non-systemic factors have been addressed such as routine skin care and elimination of allergens or infections, and a patient still experiences symptoms with itching, it is reasonable to start systemic treatment for control of atopic dermatitis. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with atopic dermatitis. Bosma and colleagues found that Dupixent can be considered a long-term effective treatment for atopic dermatitis in combination with topical and initial concomitant systemic treatment, showing a sustained improvement of signs, symptoms, and quality of life. As a chronic disease, moderate to severe atopic dermatitis typically requires long-term treatment. However, continuous, long-term use of many treatments, particularly higher-potency oral and topical corticosteroids, ultraviolet therapy, and systemic immunosuppressants are not recommended because of safety risks or lack of efficacy data. Given this support, the requested Dupixent 300 mg/2 mL pen injectors are medically necessary for 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 dermatology 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: The patient has requested authorization and coverage for intensity modulated radiotherapy (IMRT). Upon review of available data, treatment of this patients prostate primary with IMRT is likely more beneficial than standard treatment consisting of three dimensional (3D) conformal radiotherapy or no radiotherapy at all. The patient initially had widespread metastatic disease that is now bone scan negative after about one year of systemic therapy. Studies have suggested at least a failure-free survival benefit and possibly an overall survival benefit in newly diagnosed prostate patients with oligometastatic disease. This patient was initially diagnosed with widespread metastatic disease, but achieved oligometastatic disease after systemic therapy. Thus, the patient meets these criteria. In addition, imaging has demonstrated that the primary disease site is invading the bladder and rectum. Further invasion would likely drastically decrease his quality of life. Prostate radiotherapy is indicated for local control to prevent these complications. A hypofractionated course of 20 fractions to 55-60 Gy with IMRT is appropriate to minimize bladder and rectal side effects. Given this support, the requested IMRT is likely to provide this patient with a superior health outcome when compared to standard available treatment modalities. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested for gastroplasty surgery without V-Band for treatment of her morbid obesity. Findings:  Three physician reviewers found that there is a lack of long-term data in regards to outcomes and complications.  In a consensus statement released in March 2011, the American Society for Metabolic and Bariatric Surgery noted that the quality and quantity of the data available at this time is insufficient to draw any definitive conclusions regarding the safety and efficacy of the requested procedure.  Therefore, the requested gastroplasty surgery without V-Band is not likely to be of greater benefit than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis investigational for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 16 hours per week of applied behavioral analysis (ABA) services. Findings:  The physician reviewer found that the request for ABA therapy is not medically necessary for treatment of the patients medical condition. The records submitted for review document that the patient has autism spectrum disorder and has received ABA therapy for five years . The patients ABA service provider has recommended parent training due to the barriers to the implementation of direct intervention services. The providers recommendation for caregiver training to occur prior to consideration of re-introduction of direct intervention services is medically reasonable and appropriate in this clinical setting. As such, the request for 16 hours per week of ABA services is not clinically indicated for 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 pediatrics with sub-specialty certification in developmental-behavioral 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the radiofrequency neurolysis. Findings:  Two physician reviewers found that in the documentation available for review, the provider reportedly used steroids while performing the medial branch block. However, the medical literature states that medial branch blocks should be performed using either solely lidocaine or bupivacaine without sedation, and a pain diary should be kept for the day to verify when the local anesthetic wore off. Moreover, it is noted the patient still had relief from the medial branch block done on 9/8/16, almost one month later, thus the block lasted longer than the duration of the local anesthetic. For this reason, it was likely the patient would have obtained the same relief from a steroid injection in the facet joint without also having the increased risk from the radiofrequency neurolysis. Final Result: Two reviewers determined that the service at issue was 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Injection Euflexxa for the left knee at a dosing once a week for three weeks. The enrollee has a history of left knee osteoarthritis and pain. Findings:  The physician reviewer found that a magnetic resonance imaging scan performed demonstrated a degenerative complex tear of the body and the posterior horn of the medial meniscus, tricompartmental diffuse degenerative cartilage erosions, and semi-membranous tendinopathy. A repeat MRI demonstrated the addition of a small joint effusion with evidence of synovitis.  Hyaluronic acid injections were prescribed which helped her pain. An x-ray of the left knee showed severe medial degenerative joint narrowing and moderate anterior compartment degenerative joint disease.  Her orthopedist notes she has failed extensive non-surgical treatment and has recommended possible arthroscopy and Euflexxa injections of the left knee.  The patient states she was told by her prior orthopedist that as long as the injections continue to work she can delay a knee replacement surgery. Medical literature does not recommend hyaluronic acid (Euflexxa) injections.  There is no evidence that hyaluronic acid injections result in a delay of knee replacement. Additionally, studies show that it does not show superiority over other treatments; including placebo.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedics 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for deep transcranial magnetic stimulation (dTMS). In the peer-reviewed medical literature, TMS is indicated for patients with severe, recurrent major depressive disorder that has not responded to traditional medication and psychotherapy treatment. For this patient, TMS had worked successfully in the past. This patient presented to her provider with worsening of symptoms. For this course of TMS, the patient received treatment with dTMS, which involves a different coil and different depth of treatment, than rTMS. Current medical literature supports this intervention and has shown significant improvement in symptoms compared to rTMS. This patient has completed full treatment with PHQ-9 falling by 46% and resolution of suicidality attained. Therefore, dTMS was medically necessary to treat the patients condition. Additionally, dTMS was medically necessary as defined in Health and Safety code section 1374(a)(3)(A). Specifically, dTMS was medically necessary to decrease disability and correct or ameliorate the patients behavioral conditions. The services at issue were in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were appropriate in terms of type, frequency, extent, site, and duration. Based on the records, the services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Upheld

A 33-year-old male enrollee has requested total disc arthroplasty and discectomy for the treatment of his neck pain. Findings:  Three physician reviewers found that the success of joint replacement in applications such as the hip and knee has led to attempts to extend the approach to other regions. Total disc replacement in the cervical spine as an alternative to fusion offers the theoretical benefit of motion retention at the operative level and the possible salvage of adjacent joints. Early studies have reported some success, but the need for randomized, prospective studies prior to reaching any conclusions has been emphasized (Acosta and Ames). Many of the available reports are anecdotal, and also have noted the importance of extended follow-up data (Hacker). Furthermore, as the Royal Australasian College of Surgeons (RACS) report indicates, the ability of the artificial cervical disc to preserve adjacent levels has not been clarified. Thus, many questions regarding the efficacy of the procedure and the survivability of the prostheses remain unanswered and cannot be resolved until data from long-term, properly conducted studies is available (Scioscia and colleagues).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her hepatitis C virus.   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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis.`  For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Coflex spinal spacers.Findings:  Two of the three physician reviewers found this patient presents with persistent chronic low back pain with radicular symptoms, including numbness and tingling in her left leg. She had associated significant functional limitations in activities of daily living. There is reported imaging evidence of moderate spinal stenosis at the L3-4 and L4-5 levels and grade 1 spondylolisthesis. Evidence of long-term comprehensive nonoperative treatment has been submitted. The current evidence-based literature supports the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis at one to two levels. Therefore, the requested Coflex spinal spacers are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested devices 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 orthopedic surgery 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.