Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for treatment of the enrollees diffusing grade II astrocytoma.   Findings: Two physician reviewers found that proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques. The data regarding central nervous system (CNS) tumors treated with proton therapy is limited to retrospective series, small prospective studies with no strong evidence that proton beam therapy is associated with superior control rates, a decrease in toxicity or a decrease in secondary malignancies compared to treatment with conventional fractionated radiation therapy using intensity modulated radiation therapy. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support the routine use of proton therapy in the treatment of CNS malignancies. Also, the American Society of Therapeutic Radiation Oncology (ASTRO) emerging technology committee report on proton therapy states that more clinical data (published clinical trials) are needed to fully establish the role of [proton beam radiation therapy] PBT in CNS tumors. Therefore, proton beam radiation therapy has not been established as likely to be more beneficial for treatment of the patients low grade glioma than any available standard therapy.Final Result: Two reviewers determined that the requested services are 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female who is requesting reimbursement and prospective authorization for the use of Celebrex for osteoarthritis of her hip. The Health Plan has denied coverage for Celebrex indicating the patient has not undergone a sufficient trial of NSAIDs. At issue is whether Celebrex is medically necessary for treatment of the patients condition.Review of the submitted clinical evidence does not demonstrate that the medical necessity of a Cox-2 inhibitor (Celebrex) has been established. There are a number of NSAIDs available, and the medical records do not demonstrate NSAIDs are contraindicated or have been ineffective. Thus, there is no evidence that Celebrex is medically necessary at this time. Therefore, I have determined that the medication at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 67-year-old male enrollee has requested for chemotherapy regimens Thalomid, Leukine and Revlimid for treatment of his prostate cancer. Findings:  Three physician reviewers found that there is a lack of data that validates the requested combination for prostate cancer.  There is data supporting the use of Thalomid in the literature, and this therapy is medically indicated and appropriate.  However, there is a lack of data supporting the use of Revlimid and Leukine for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested a bilateral labiaplasty for the treatment of her congenitally enlarged labia minora. Findings:  The physician reviewer found that labiaplasty is performed to alter the size or shape of the labia majora or labia minora. To determine whether this vaginal surgical procedure is medically necessary, the Committee Opinion of American College of Obstetricians and Gynecologists (ACOG) has recently reported on the indications for the procedure. According to the ACOG, Medically indicated surgical procedures may include reversal or repair of female genital cutting and treatment for labial hypertrophy or asymmetrical labial growth secondary to congenital conditions. The submitted documentation does not demonstrate that the patients condition meets criteria for labial hypertrophy or asymmetrical labial growth secondary to congenital conditions. The ACOG indicates procedures such as labiaplasty are not medically necessary if the above criteria are not met. The submitted evidence does not demonstrate that a labiaplasty is medically necessary for this patient. With regard to whether the proposed procedure is reconstructive in nature, based on the documentation provided, the patients condition does not constitute an abnormal structure of the body. As noted above, the patients condition is not consistent with the indications of labial hypertrophy or asymmetrical labial growth secondary to congenital conditions. The patients labia are within the range of normal variation of pelvic anatomy. The structures are not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. As such, the patients condition does not meet the requirements for reconstructive surgery as set forth by California law.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested authorization and coverage for a PET/CT scan for evaluation of her breast cancer. Findings:  The physician reviewer found that the National Comprehensive Cancer Network guidelines do not advocate for the use of PET/CT scans in patients with stage I or stage II breast cancer.   Niikura and Ueno reported that there is limited evidence to support the use of PET/CT scans in the initial staging of primary breast cancer.  The authors noted that for cases in which conventional imaging techniques do not provide adequate information, PET/CT scans could be used to obtain more detailed anatomical information.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings: The physician reviewer has found that the current medical evidence supports the requested medication regimen in this clinical setting.  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 a first-line regimen for non-cirrhotic treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Epclusa once daily, for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 52-year-old female enrollee requested authorization and coverage of spinal cord monitoring during spinal fusion surgery for the treatment of severe back pain.  The health plan denied the enrollees request indicating that the requested spinal cord monitoring is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested monitoring is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for adult partial hospitalization level of care for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that addiction specialty services and psychotherapy are indicated, the clinical documentation does not demonstrate the medical necessity for partial hospitalization at this time.  This patient is sorting through identity and phase of life issues, but there is no evidence that the current level of care is either unsafe or inadequate. Per the records, the records noted improved sleep. He had no sadness, irritability or rumination. Although still a challenge, he was leaving the home at least once a day.  He was developing more interest in activities. He was actively engaged in the therapeutic process and was incorporating elements of behavioral activation. His sobriety was intact.  He had no acute psychiatric issues or safety concerns, while validated clinical rating scales evidenced a significantly less burdensome symptom complex. The provider indicated that the patient was benefitting from the placement. There was no evidence of cognitive impairment, substance use or an acute psychiatric syndrome. The patient was not taking any psychotropic medication aside from the buprenorphine. The providers plan was to continue intensive outpatient programming, while there was no mention that a higher level of care was indicated. As such, adult partial hospitalization level of care is not medically necessary for the 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 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: Upheld

The patient is a 49-year-old woman who has requested authorization and coverage for Rocephin for treatment of neuroborreliosis. The patient has a history of being treated for Lyme disease in 1994. There are no subsequent notes to suggest pathognomonic clinical findings. The patient was treated with three weeks of a tetracycline antibiotic. At about the same time, the patient began to develop neurological signs and findings very suggestive of multiple sclerosis and was given this diagnosis by a neurologist. Review of the materials provided indicates the results of the patients clinical examination, MRI and cerebrospinal fluid (CSF) examination were consistent with this diagnosis. Although there is no evidence the patient has ever had positive serologies for Lyme disease, there is a note about a positive CSF for a borrelia antigen (OspC). The patient was also said to have had a positive IFA for babesia.The patient apparently initially received Rocephin from 1995 to 1996. The patient then received Rocephin from August 2001 to July 2002. Treatment with Rocephin was then reinitiated from October 2003 to at least January 2004. In addition, the patient has received extensive oral antibiotic therapy (e.g., Ceftin, Zithromax and Flagyl).There is no evidence that additional therapy with Rocephin is likely to benefit the patient. The cited study by Krupp et al., demonstrates that in a blinded, placebo-controlled trial antibiotic treatment for this condition was ineffective. Two randomized controlled trials of this disease demonstrated no benefit with 90 days of antibiotic therapy in patients with persisting symptoms. Furthermore, the recent articles note that no scientific evidence supports the practice of giving antibiotic therapy for months or years given the lack of efficacy and the possibility of adverse effects.There do not appear to be any trials that would support the continued use of antibiotics in this patient. While it is true that the borrelia antigen may persist in the CSF for extended periods, evidence suggests that rather brief periods of therapy (e.g., one month) with Rocephin are able to eliminate evidence of infection. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 48-year-old female enrollee has requested authorization and coverage for Avonex. Findings:  The physician reviewer found that Avonex is U.S. Food and Drug Administration (FDA) approved and has been demonstrated to be effective in the treatment of MS. Avonex has been shown to reduce relapses and disability progression. Studies show interferons are similar efficacy to glatiramer. Avonex is an intramuscular injection, rather than subcutaneous, which has not been noted to cause injection site reactions. Moreover, Avonex is a weekly treatment rather than three times a week, which encourages patient compliance. All told, Avonex is medically necessary for treatment of this patients MS. 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 neurology 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

The parent of a four-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech disorder. Findings:  The physician reviewer found that review of the relevant medical literature regarding the etiology, symptoms, ages and treatment of childhood dysfluency revealed no evidence of a medical cause for the etiology of childhood stuttering. The available evidence suggests the average age of children with childhood dysfluency is three to five years old.  In 60-80% of these children, the dysfluency resolves spontaneously. The use of speech therapy in the treatment of speech dysfluency is not within the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested for tubal ligation revision surgery for treatment of her status post tubal ligation. Findings:  The physician reviewer found that noted by Westcoff and Davis, for women 30 years of age and older, there is no consistent evidence indicating that tubal sterilization is associated with an increased risk of dysmenorrhea, menstrual dysfunction, or increased premenstrual distress.  As noted by the American Congress of Obstetrics and Gynecologists Practice Bulletin, recent studies have found little different in menstrual patterns between sterilized women and non-sterilized controls in the first one to two years of follow-up. The current medical evidence does not support the procedure.  All told, tubal ligation revision surgery was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for HP Acthar Gel 80 Units twice a day (BID) for three months and then HP Acthar Gel 40 Units BID for three months. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the management of nephrotic syndrome. Acthar Gel is supported as safe and effective for patients who are refractory or intolerant of the typical agents used as first- and second-line therapies. Researchers found that Acthar Gel may meet an important treatment need in patients with treatment-resistant nephrotic syndrome in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has exhausted many standard treatments. She has advanced disease is at high risk for further progression. Given the support in the medical literature, the requested HP Acthar Gel 80 Units BID for three months and then HP Acthar Gel 40 Units BID for three months is 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 internal medicine with subspecialty certification in nephrology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that the request for Otezla is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has not had a trial of treatment with a conventional disease-modifying antirheumatic drug (DMARD) such as methotrexate or leflunomide. In addition, there is a lack of documentation demonstrating that conventional medications have been exhausted. Based on the medical records and peer-reviewed guidelines for the treatment of psoriatic arthritis, the request for Otezla is not medically necessary for treatment of the patients psoriatic arthritis. 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 internal medicine with sub-specialty certification in rheumatology 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 authorization and coverage for Nexium 40 mg twice per day for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: The physician reviewer found that compared with brand name medications, generic formulations may contain additional inactive ingredients such as dyes. Although differences in efficacy between generic medications and brand name medications have not been widely demonstrated, differences in tolerance and adverse effects may be present. The records document that this patient has already failed one generic formulation of Nexium. Therefore, the requested coverage of brand name Nexium is supported as medically necessary in this case. However, the use of Nexium 40 mg twice daily rather than once daily is not supported. The American College of Gastroenterology guidelines recommend twice-daily therapy when once-daily therapy is insufficient to control GERD symptoms and esophagitis. Despite this recommendation, the dose of esomeprazole 40 mg twice daily (80 mg per day) is not recommended and is not approved by the U.S. Food and Drug Administration (FDA). Higher doses of proton pump inhibitors can be associated with adverse effects such as osteoporosis (Fraser, et al). Furthermore, the patient has not reportedly been treated with Nexium 20 mg twice daily. For these reasons, the requested treatment with brand name Nexium 40 mg daily is supported as medically necessary for the treatment of this patients GERD, but Nexium 40 mg twice daily is not supported as medically necessary.Final Result: The reviewer determined that a portion of the requested medication 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 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

The parent of a 15-year-old female enrollee has requested psychiatric residential treatment services for treatment of the enrollees depressive disorder and anxiety disorder. Findings:  The physician reviewer found that there is an established protocol to increasing levels of care to support use of the least restrictive treatment setting possible for an individual patient (Pliszka, et al). This patient was and is a candidate for outpatient treatment including individual therapy, family therapy, group therapy, and increasing visits with her psychiatrist. Residential treatment programs are considered medically necessary for patients who have failed intensive work at home and require medical and/or psychiatric monitoring 24 hours per day by trained providers. Overall, the records do not provide evidence that the patient required the intensity of treatment provided at the residential treatment program level of care. Therefore, the services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for air ambulance transportation.  According to the American College of Emergency Physicians and National Association of Emergency Medical Services (EMS) Physicians guidelines, patients requiring critical interventions should be provided those interventions in the most expeditious manner possible. The guidelines note that, patients who require high-level care during transport, but do not have time-critical illness or injury, may be candidates for ground critical care transport. In this case, the patient sustained a severe right acetabular fracture requiring care at a medical facility with orthopedic surgical expertise. He was transferred to a high-level rehabilitation facility. The patient was transferred by air ambulance almost two weeks postoperatively to a lower level of care to be closer to home. There is no indication that the patient was unstable or had a condition that could not have been managed at the initial facility. The submitted records do not document that the patient required air transport over ground transport or that the patient had any medical conditions that precluded ground transport. All told, the air ambulance transportation was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.