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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the RTC level of care services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 with expertise in addiction 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: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested Botox injections every 3 months for treatment of her migraine headaches.  Findings:  Two physician reviewers found that recently the FDA approved Botox as a treatment for chronic migraine. There is insufficient documentation however in this patients records to ascertain whether her symptoms are consistent with chronic migraine. Additionally, it appears she has not been treated with Valproic acid or tricyclic antidepressants and there are no details regarding the medications trialed. Thus, there is inadequate information to diagnose this patient with chronic migraine or that Botox is likely to be more effective for relief of her headaches in lieu of standard, conventional therapies. As such, the requested therapy was correctly classified as investigational in this circumstance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 10-325 oxycodone-acetaminophen tablets to be taken once every six hours as needed for pain for treatment of lupus, chronic neutropenia and myasthenia. Findings:  The physician reviewer found that the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative setting. However, in this case not all non-opioid treatment options have been utilized. The records did not mention the completion of behavior therapy despite much research to support its use. It is also reasonable to consider alternatives to opioids and to wean the patient to a lower dose of opioids or even off opioids. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. Moreover, even in the post surgical setting, opioids should be returned back to their preoperative status within a few weeks, and there are issues with opioid prescribing even in the postoperative setting. Also, several requirements for opioid prescribing have not been documented and the need to use them as the primary medication treatment strategy for this patient has not been established. Finally, not all non-opioid medications classes have been optimized or tried. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the fetal chromosomal aneuploidy genetic testing. Findings:  Two out of three physician reviewers found that the enrollee presented at twelve weeks gestation for genetic counseling due to advanced maternal age. Paternal family history is positive for autism and liver disease. She planned to complete the California prenatal integrated screening and was also considering expanded carrier screening and/or cell-free DNA screening. Cystic fibrosis, spinal muscular atrophy, and Fragile X carrier screening results were pending through her obstetricians office.  The cfDNA detects Down syndrome with 99 percent efficiency.  Guidelines consider it the most sensitive screening option for detecting trisomy 21, 18, and 13. Cell free DNA is a standard of care for high-risk enrollees. Studies demonstrate DNA-based testing of maternal plasma for high-risk enrollees can detect fetal abnormalities with a high degree of accuracy. These studies form the basis for the recommendation of this diagnostic. Ante-natal screening can increase the likelihood of identifying an abnormal fetus and reduce the number of invasive diagnostic tests and procedure-related losses of normal fetuses. This enrollee was counseled by her geneticist that she was at greater risk for fetal chromosomal aneuploidies due to her advanced maternal age and gestational diabetes. The risk of Down syndrome for this age group is estimated to be 1 in 267. The risk of any chromosomal abnormality is 1 in 148. An aneuploidy screening discussion is recommended for all women early in pregnancy; ideally at the first prenatal visit. The standard aneuploidy screening includes a nuchal translucency ultrasound exam in the first trimester, with maternal serum PAPP-A and HCG levels, and the Quad screen in the second trimester; which measures maternal serum levels of HCG, AFP, inhibin A, and estriol.  Using these screening exams, the detection rate for Down syndrome is about 95%. With cell-free DNA screening, the detection rate is as high as 99.9%. Cell-free DNA prenatal screening is superior to standard first and second trimester screening tests.  Because of the higher precision of this test, as compared to standard prenatal screening, many enrollees can avoid invasive diagnostic testing; such as chorionic villus sampling (CVS) or amniocentesis. The lower false positive rate found with cell-free DNA prenatal screening may also contribute to enrollee preference for this diagnostic. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard testing for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. It is well established that ABA therapy is a standard modality for the treatment of children with autism. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In this patients case, the submitted documentation does not demonstrate the patient has achieved substantial or sustained gains in IQ, language, academic performance, and adaptive/social behavior with ABA therapy. The patient is non-verbal and his adaptive skills are at an age equivalency of a 2 to 3 year old at a chronological age of 12 years. The gains in goals cited in his ABA progress reports do not reflect significant improvement. Given that the patients overall response to ABA therapy has been limited, the medical necessity of the disputed services has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiation therapy (SBRT) for treatment of the enrollees pancreatic cancer.  Findings: Two reviewers found that the patient with a recent diagnosis of unresectable pancreatic cancer who presented to the emergency room with symptoms of abdominal pain, jaundice and dark urine. A computed tomography (CT) showing a pancreatic head mass abutting the superior mesenteric vein (SMV), narrowing the proximal portal vein, and abutting the celiac artery. Esophagogastroduodenoscopy/endoscopic ultrasound (EGD/EUS) and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a pancreatic neck mass involving the portal vein confluence and celiac artery. The MRI also showed regional lymphadenopathy including a celiac node. Repeat EGD/EUS on eventually demonstrated adenocarcinoma on pathology. The patient has been referred to radiation oncology for stereotactic body radiation therapy (SBRT) for persistent disease. The Health Plan denied the requested services as investigational for treatment of this patient. Upon review of available data, SBRT is likely to be more beneficial in the treatment of locally advanced (unresectable) pancreatic cancer as compared to standard therapy consisting of conventionally fractionated radiotherapy. The 2016 American Society of Clinical Oncology (ASCO) Clinical Practice Guideline guidelines support the use of SBRT for the treatment of locally advanced pancreatic cancer with the quality of data supporting its use being assessed as intermediate. There are also other potential benefits of local control with regards to quality of life in preventing abdominal pain and bowel obstruction. Overall, there is a significant benefit in local control with SBRT with a small increase in toxicity. All told, the requested stereotactic body radiation therapy (SBRT) are likely to be more efficacious than current available methods in the treatment of this patient.Final Result: Two reviewers determined that the requested services are 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 physician reviewers are 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested epidural steroid injection for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has pain complaints and physical examination findings that are corroborated by MRI studies.  He has failed to respond to conservative measures including physical therapy, massage therapy, medications and rest.  The current medical evidence supports the requested epidural steroid injection in this clinical setting.  All told, the requested epidural steroid injection is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 46-year-old male enrollee has requested inpatient substance abuse treatment for the treatment of his chemical dependency. Findings:  The physician reviewer found that the patient presented with methamphetamine use 1-2 times per week according to the history provided in the medical records. He denied use of alcohol, marijuana or other substances. He presented with no withdrawal symptoms and with no history of psychiatric co-morbidity or major medical co-morbidity. It was reported that his mood was euthymic, with no suicidal ideation, no psychosis, and his memory was intact.  He was working and was involved with a court program. The medical records indicate he was active in an outpatient treatment program and the progress notes indicated the patient had been clean for 42 days. The level of care provided is consistent with practice guidelines and level of care utilization system guidelines. Given the patients functional status, the absence of significant co-morbidities, and his level of involvement in outpatient treatment, the medical necessity for a higher level of care is not evident in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested for robotic-assisted laparoscopic radical prostatectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that there is no superiority of survival with the requested procedure. Robotic-assisted laparoscopic radical prostatectomy is not likely to be more efficacious than standard techniques.
Appeal type: Medical Necessity
Decision: Overturned

A 67-year-old male enrollee has requested services be performed by his dentist for the treatment of his sleep apnea. Findings:  The physician reviewer found that the Health Plan indicated that the services at issue were outside the scope of practice of a dentist. The patients provider has made no claim that he is a sleep specialist, only that he is a DDS that specializes in craniofacial pain and associated temporomandibular disorders and their treatment. This includes fabrication of MRDs that are used to treat OSA. His role was to provide an MRD on the recommendation by prescription of another sleep specialist. The diagnostic studies performed in the course of the evaluation prior to fabrication of the MRD were medically necessary and appropriate to determine the patients suitability for the device and ensure that using the device would not cause undue or further harm to the patient after application.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation the enrollees major depressive disorder and post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The medical literature lacks well-designed and adequately powered studies illustrating consistent and reproducible results that provide clinically useful information pertaining to genomic testing and its relationship to specific pharmacologic interventions.  In this case, the patient tried many medications and had frequent medicine changes. However, there is a lack of documentation demonstrating the specific type and duration of psychotherapies provided, which are standard therapies that often outperform psychotropic medication. For example, evidence-based trauma-focused therapies for PTSD, interventions for depression such as cognitive behavioral therapy, interpersonal therapy or psychodynamic therapy, and, considering the chronic suicidality and family stress, dialectical behavior therapy and family counseling, respectively, may have been more appropriate at the time.  In sum, the records do not support that the patient had exhausted standard treatments available to treat her condition. In conclusion, considering the relevant peer-reviewed literature and current practice standards, the genetic testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. All 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 41-year-old female enrollee has requested a bilateral reduction mammaplasty for treatment of her enlarged breasts.  Findings:  The physician reviewer found that there is insufficient medical documentation to approve the requested breast reduction surgery. Since the submitted documentation does not include an examination by a surgeon indicating the estimated tissue expected to be removed from each breast, it would first be necessary for her to be evaluated by a specialist to determine whether she may in fact be an appropriate candidate for the requested procedure. The patients records adequately support the need for a consultation with an in-Plan plastic surgeon as the records document chronic low back and shoulder pain in addition to the patients shoulders showing bruises from her bra straps. Thus, a surgeon should further explore and document the patients need to have breast reduction surgery.
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: Two physician reviewers found that  there is sufficient support for the services at issue in this patients case. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone.  Final Result: Two 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. Al 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: Urgent Care
Decision: Upheld

A 36-year-old female enrollee has requested for an emergency room (ER) visit for care of her neck pain. Findings:  The physician reviewer found that the records provided do not support that this patients symptoms meet the prudent layperson definition of an emergency.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that the patient was evaluated with screening mammogram and breast tomosynthesis.  The Health Plan has denied the tomosynthesis portion of the examination as investigational.  Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the examination had been performed using the two dimensional technique alone.Final Result: Two physician 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.Credentials/Qualifications: All three physician 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: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested proton beam radiotherapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that the providers letter states that proton therapy is safe and effective and that there is accumulating evidence that it is a superior means to deliver high dose radiation. Although proton therapy for prostate cancer is an accepted treatment approach, other treatment approaches including IMRT and image guided radation therapy (IGRT) are also highly effective and well tolerated. Further, there is a paucity of compelling data to suggest that proton therapy is superior to or more beneficial than these standard alternatives. As a result, the generally accepted standard is to only offer proton beam therapy as part of a clinical trial. Thus, the requested proton beam radiotherapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.