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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multi-functional foam support system for treatment of the enrollees back pain. Findings:  The physician reviewer found that the request for multi-functional foam support system is not medically necessary for treatment of the patients medical condition. In general, durable medical equipment (DME) is recommended due to a medical need and if the device or system meets the Medicare definition of DME. In this case, the requested foam wedge zero-gravity comfort and support system does not serve a medical purpose and is primarily used for convenience in the home. It does not meet the definition of DME. In addition, the patient does not have evidence of a current pressure ulcer or failure of treatment for a pressure ulcer which would support mattress overlay. The patient is able to ambulate with an assistive device and is not immobilized. For the reasons provided, the requested equipment has not been established as medically necessary for the treatment of the 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 physical medicine and rehabilitation 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. The Health Plan has denied this request indicating the enrollee was not experiencing an emergency medical condition on the date of service at issue.Findings: At issue in this case is whether the enrollee received emergency medical services on the date(s) 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 patient did not receive emergency services and care provided as defined by the California Health and Safety Code  1317.1 (a)(1).  The records demonstrate that this patient presented for a scheduled sleep study evaluation. His vital signs were documented as normal and he was asymptomatic at the time of his arrival. Sleep studies to assess for sleep apnea are routinely scheduled on an outpatient basis. There were no indications for an emergency sleep study evaluation. The services at issue 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.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient has multiple obesity-related comorbidities that will be eliminated or ameliorated by bariatric surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Butrans patches for treatment of the enrollees chronic pain. Findings: The physician reviewer found that in the documentation available for review, not all non-opioid treatment options have been utilized. Behavior therapy has not been provided despite much research to support its use (Lee, et al; Flor). Instead, large doses of opioids are being used, with a daily morphine equivalent (MEQ) dose that exceeds 120 MEQ despite research showing the dangers of such high dosing (Moulin, et al). In addition, the Centers for Disease Control and Prevention (CDC) recommends against use of this level of MEQ, not prescribing opioids with benzodiazepines, use of urine drug screens, using state prescription monitoring programs, and avoiding long acting opioids (Dowell, et al). Given the patients history of addiction to opioids, being on benzodiazepines, and overuse of prescription opioids, any continuation of opioids should be under the direct guidance of a mental health professional (Blasco-Fontecilla, et al). All told, the requested Butrans patches are not 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 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 56-year-old male enrollee has requested iron and ferritin infusionsfor treatment of his polycythemia vera (PV).  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. The use of intravenous iron and ferritin for this patient is not clinically indicated and in fact is contraindicated. This patient carries a diagnosis of polycythemia which is possibly secondary to androgen use (the patient is on testosterone) given that he has no platelet or white blood cell abnormality, a normal to elevated epogen level and a negative mutation in JAK2. The patient had a bone marrow biopsy showing absent iron storage which is found in 94% of patients with polycythemia (Tefferi, ref. 1). The goal of phlebotomy is to produce a state of relative or absolute iron deficiency and iron supplements should not be given (Tefferi, ref. 2). The use of iron is contraindicated and contributes to the problem by continuing to increase the hemoglobin and hematocrit that phlebotomy is intended to reduce. There is no documentation that this patient is suspected to have iron deficiency anemia which would be the only reason for him to need iron (Schrier and Auerbach). On the date specified the patient had a normal ferritin of 61 as well as normal iron indices on the date specified indicating that he is not iron deficient. In conclusion, the medical necessity of the requested therapy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Xifaxan for treatment of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Xifaxan is being requested to treat bacterial overgrowth.  This indication has been studied, and Xifaxan has proven highly effective for eradication of bacteria and for symptom relief in randomized and retrospective studies at high dose. The medication had greater effectiveness with fewer side effects than alternatives.  Per the medical evidence, results are sustained for several weeks after treatment.  Xifaxan treatment has also proven to alleviate symptoms in patients with irritable bowel syndrome with positive breath test for bacterial overgrowth.  All told, Xifaxan is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 45-year-old female enrollee has requested Protopic for treatment of her cicatricial alopecia and lichen planus pigmentosus.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. The documentation submitted for review indicates that the patient has been treated with intralesional steroid injections to the scalp, but there is no follow-up documentation as to its effectiveness. The medical records also do not indicate that a trial of topical steroids has been tried and failed. Given that cases of cicatricial alopecia are often refractory to therapy, intralesional, high potency topical steroids or oral immunosuppressive agents are often needed to reduce the inflammation associated (Harries and Messenger; Racz et al). According to Harries and Messenger intralesional steroid injections are the most effective treatment in this patients case. Furthermore, the patient is also being treated for lichen planus pigmentosus of the face and neck and there is no documentation as to having failed a trial of a mild to moderate potency topical steroid. Given that Protopic is not likely to benefit the scalp and that a trial of a mild to moderate topical steroid on the face has not been tried, the request for Protopic ointment is not clinically indicated. Thus, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power wheelchair. The records indicate that this patient has sustained multiple strokes and presents with residual left-sided weakness. The records provided for review from October 2019 noted normal upper limb strength bilaterally and good lower limb strength bilaterally. She had functional active range of motion in the limbs. She demonstrated mild difficulties using her left hand. Based on the available records, the patient meets the criteria for a manual wheelchair. The patient may require a manual wheelchair with one-arm drive if her left upper limb motor function is too impaired, and the device should be fitted to allow for self-propulsion with the legs. The patient should be able to perform adequate pressure relief given that she can perform independent bed to wheelchair transfers. There are no indications in the records to establish that the patient would be bed or chair confined without a power mobility device. The patient should be able to attend college and medical appointments with a manual wheelchair. Moreover, the patient is noted to be obese. She would benefit from exercise, such as that afforded by regular use of a wheelchair propelled by her own body power. Obesity management requires comprehensive lifestyle approaches, including recommendations for exercise. Given these findings, the requested power wheelchair is not medically necessary for 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 upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 patients parent has requested authorization and coverage for services at a tertiary level of care. Ehlers-Danlos syndrome is an inherited collection of disorders of connective tissue, with signs and symptoms involving hyperextensibility of the skin, hypermobility of joints, and tissue fragility. Arthrochalasia-type Ehlers-Danlos syndrome is characterized by frequent dislocations of major joints, hypermobility, and in some cases, genetic intractable nausea and vomiting. These signs and symptoms are consistent with this patients presentation. Pain is a significant issue in these patients because of tissue damage, joint damage, dislocations, and previous surgeries. This patient initially presented to his provider with abdominal pain, constipation, and nausea. As he got older, his symptoms became more severe, so that he now experiences near-continuous nausea with vomiting. He has since received a diagnosis of arthrochalasia-type Ehlers-Danlos syndrome. His symptoms were well-managed in the past by his pediatric gastroenterologist. Despite his diagnoses of autism and attention-deficit/hyperactivity disorder (ADHD), the provider was able to connect with the patient and they developed a good working relationship. Now that his symptoms are debilitating, it is even more important to have a good working relationship with his provider, taking into consideration all of his medical problems and mental health diagnoses. Given these findings, the requested services at a tertiary level of care are medically necessary for 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 pediatrics with subspecialty certification in pediatric critical care 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 53-year-old male enrollee has requested for a trabeculotome procedure for treatment of his pigmentary glaucoma.   Findings:  Three physician reviewers found that there is no information available in the literature to support a trabeculotome procedure over a trabeculectomy, with or without anti-metabolites. Although the trabeculotome procedure is newer than the gold standard trabeculectomy, and it could be considered slightly less invasive, the long-term benefits and side effects are not yet known.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with anxiety disorder, insomnia, and obstructive sleep apnea. Per the records, he has been treated with Xanax, Ambien, trazodone and temazepam. The provider noted the patient had been seen by a psychiatrist in the past, but he did not want to take the medication that was recommended. The patient requested a refill of Xanax for daily use due to anxiety. The provider noted that daily use of Xanax was not an appropriate treatment for the management of anxiety. The provider prescribed Xanax 0.5 mg with a quantity of 10 to use as needed. The patient requested Xanax for chronic insomnia. He has requested authorization and coverage for Xanax 0.5 mg tablets, 30 tablets per 30 days. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Xanax 0.5 mg tablets, 30 tablets per 30 days is medically necessary for the treatment of the patients medical condition. The British Psychological Society reported, A wide range of medicines with differing pharmacological properties can be effective in the treatment of generalized anxiety disorder (GAD). Traditionally, benzodiazepine drugs, such as diazepam, were employed for this purpose but it became clear that their use was commonly associated with the development of tolerance and dependence. For this reason, they are now recommended only for short-term use (two to four weeks). Kryger and Malhotra reported medications that may exacerbate obstructive sleep apnea (OSA) and theoretically worsen daytime sleepiness include benzodiazepine receptor agonists, barbiturates, other antiepileptic drugs, sedating antidepressants, antihistamines, and opiates. Wang and colleagues reported, recent benzodiazepine use (one to 30 days) increases the risk of adverse respiratory events and subgroup analysis suggested benzodiazepine use increased the risk of acute respiratory failure. In this case, the patient has been diagnosed with anxiety disorder, insomnia, and obstructive sleep apnea. The patient requested Xanax for daily use due to insomnia and anxiety. The medical evidence does not support the requested medication in this clinical setting. Therefore, Xanax 0.5 mg tablets, 30 tablets per 30 days are not medically necessary for the treatment of this patient. 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 with sub-specialty certification in geriatric 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 partial hospitalization program services for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Initially, the patient had neither demonstrated the ability to maintain weight nor consolidated the treatment gains necessary to succeed in a less restrictive setting.  Thus, discharge at that time would have been consistent with inadequate care.  Thereafter, the patient continued to engage in active treatment services.  The patient was both psychiatrically and medically stable, and he was future oriented.  This patients anorexia nervosa necessitated comprehensive specialty care, and the partial hospitalization services were safe, appropriate and consistent with good medical practice initially.  However, based on the patients progress and clinical stability despite the chronicity of the illness, the records did not suggest that partial hospitalization would further improve the patients condition and/or prevent a more serious episode of illness superiorly to well-coordinated services delivered in a less restrictive setting.  All told, partial hospitalization program services provided initially were medically necessary, but not thereafter. 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 partially 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: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested for a vaginal birth after cesarean (VBAC) for treatment of her pregnancy.   Findings:  The physician reviewer found that there is no current medical evidence suggests that VBAC should be viewed as unsafe or below the generally-accepted standard of medical care. The American College of Obstetricians and Gynecologists (ACOG) has established guidelines and recommendations which need to be discussed with women who wish to undertake a VBAC, since, after a single low-transverse cesarean section, there is a slightly increased risk of uterine rupture with labor (0.5  1.0%). The vast majority of women who attempt VBAC do, in fact, have completely uncomplicated and straightforward vaginal deliveries, with no significant perinatal complications. Still, the role of VBAC remains controversial even in the current state of obstetric practice.