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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure. Scientific evidence has not been established via well-designed controlled studies with adequate follow-up demonstrating safety and efficacy of the use of the LINX procedure. In addition, direct comparative studies between surgical interventions are needed to better assess the safety and efficacy of the LINX procedure. There is lack of randomized controlled trials comparing LINX with other surgical anti-reflux interventions, such as the Nissen fundoplication. Researchers concluded that the long-term safety and efficacy of LINX remains to be determined by evaluating and investigating the safety, efficacy, and durability of the intervention over time. Adverse events including erosion through the esophagus have been reported. Although the LINX device has been approved by the U.S. Food and Drug Administration (FDA), based on current evidence and medical literature, the technology has not met a consensus opinion or recommendation by medical societies and governing organizations. Overall, the LINX procedure has not been thoroughly evaluated in randomized controlled trials against other alternative therapies to support its use in this patient with GERD who has experienced partial symptomatic relief with medical therapies. Accordingly, the requested LINX procedure (magnetic esophageal sphincter augmentation) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested LINX procedure (magnetic esophageal sphincter augmentation) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that The requested 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with Subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee requested applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder (pervasive developmental disorder). Findings:  Two physician reviewers found that, based on the available medical literature, the requested ABA therapy is supported as medically necessary for treatment of this patients autism spectrum disorder. ABA therapy is well-established as a standard modality for individuals with autism spectrum disorder. Specific treatment, including ABA therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that cause developmental delays and social disconnection associated with autism spectrum disorder. Consistent with these findings, the requested ABA therapy is medically necessary for treatment of this patients autism spectrum disorder.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Simponi (golimumab) 50 mg/0.5 mL injection once monthly. Researchers noted, In adults with active ankylosing spondylitis despite treatment with nonsteroidal anti-inflammatory drugs, we strongly recommend treatment with tumor necrosis factor inhibitors (TNFi) over no treatment with TNFi. The authors did not recommend any particular TNFi as the preferred choice, and further stated, In adults with active ankylosing spondylitis despite treatment with the first TNFi used, we conditionally recommend treatment with a different TNFi over treatment with a non-TNFi biologic in patients with secondary nonresponse to TNFi. In this case, the patient has a diagnosis of ankylosing spondylitis. She is unable to tolerate NSAIDs and was unable to tolerate treatment with her first TNFi, Humira. Given current medical literature, treatment with a different TNFi, such as golimumab, is standard of care and medically indicated. Therefore, Simponi (golimumab) 50 mg/0.5 mL injection once monthly is medically necessary 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for embryo genetic testing (CPT codes 99000, 81228, and 88299). Fragile X premutation carrier screening is recommended for patients with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome, and who are considering pregnancy or are currently pregnant. The American College of Obstetricians and Gynecologists (ACOG) identified that patients with intermediate results and carriers of a fragile X premutation or full mutation should be provided follow-up genetic counseling to discuss the risk to their offspring of inheriting an expanded full-mutation fragile X allele and to discuss fragile X-associated disorders. Carrier screening and counseling performed before pregnancy enables couples to learn about their reproductive risk and consider the most complete range of reproductive options, including whether or not to become pregnant and whether to use advanced reproductive technologies such as preimplantation genetic diagnosis or use of donor gametes. This patient underwent PGTA based on her abnormal screening, which demonstrated that she is a carrier for Fragile X syndrome. Given these findings, the embryo genetic testing (CPT codes 99000, 81228, and 88299) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the embryo genetic testing (CPT codes 99000, 81228, and 88299) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in pediatrics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested osteochondral allograft transplant for treatment of his medical condition.   Findings:  Three physician reviewers found that the submitted documentation does not demonstrate the superior benefits of the requested services.  Osteochondral allograft is not indicated as a salvage procedure for advanced osteoarthritis, such as in this case.  Osteochondral allograft transplantation has been demonstrated to be a safe and effective treatment of large osteochondral and chondral defects of the knee in appropriately selected patients.  Higher rates of successful allograft transplantation are observed in younger patients, unipolar lesions, normal or corrected malalignment, and defects that are treated within 12 months of symptom onset.  Patients with bipolar lesions, uncorrectable malalignment, advanced osteoarthritis and those over 40 tend to have less favorable outcomes.  In this case, there is no single osteochondral defect, but rather eburnation of the medial compartment is described by the radiologist with advanced osteoarthritis of the medial compartment and moderate changes in the patellofemoral joint.   The allograft will be bipolar and large in size.  A review of the literature indicates that such allografts usually fail.  In sum, the requested osteochondral allograft transplant is not likely to be more efficacious than standard treatments.   Final Result: Three 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 reviewers are board certified in orthopedic surgery 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: Overturned

A 44-year-old male enrollee has requested for PET/CT scan for evaluation of his aggressive digital papillary adenocarcinoma.   Findings:  Three physician reviewers found that Lymphatic mapping and sentinel lymph node biopsy are useful in detecting early metastases. There is also one report of a pulmonary metastasis detected with CT. In this patient, PET/CT did identify a positive axillary node (twelve nodes biopsied, one was positive). PET/CT is useful in this patients tumor. An initial follow-up PET/CT should be approved at six months. Subsequent scan approval should be based on the clinical situation at the time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old male who became dependent on Vicodin due to chronic back pain. His physician recommended utilization of Subutex for both withdrawal and maintenance therapy. The detoxification went fairly well, but the patient later filled prescriptions for Vicodin and hydrocodone tabs. The record does not provide a detailed account of his providers response to his breakthrough use of narcotics. His subsequent request for authorization of Suboxone was denied by the Health Plan based upon their determination that concurrent use of narcotic medications and Suboxone is not medically necessary.The National Institute of Health (NIH) has outlined a protocol for the use of Subutex/Suboxone for detoxification and maintenance of abstinence from narcotic medications. The patient met the criteria for the use of Subutex/Suboxone and appeared to follow the protocol during the detoxification phase of his treatment. He was however, unable to tolerate the maintenance phase and filled prescriptions for a substantial amount of narcotics. Although the NIH protocol allows for breakthrough use of narcotic medications, the protocol requires a clear plan of corrective action to regain the state of abstinence from all narcotics in order to continue on the Subutex/Suboxone protocol. A review of the progress notes from the patients provider did not reveal a clear corrective action plan following the patients relapse or explain how the large quantity of prescription medications would be collected from the patient. The circumstances surrounding the patients use of narcotics during the Subutex/Suboxone maintenance phase raise serious questions and concerns about his commitment and the efficacy of this course of treatment that did not appear to be adequately addressed by the attending physician. Therefore, I have determined the requested medication is not medically necessary for 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: The parent of an enrollee has requested authorization and coverage for a procedure to remove a mole from the back.At issue is whether the requested procedure to remove a mole from the back is medically necessary to treat the patients medical condition. In addition, does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, disease. If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Nevi (moles) are common congenital and/or acquired lesions that are seen on the skin. They can vary in size and number. Indications for removal are the presence of clinical atypia or  lesions that have become inflamed/traumatized and cause significant discomfort or pose a threat (i.e. infection or bleeding). In this case, there appears to be evidence that the lesion is at least inflamed. The lesion is erythematous and covered with a band-aid in the submitted photograph. The patients parent reported that the patient experiences distress and discomfort from the lesion. Therefore, the requested procedure to remove a mole from the back is medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the mole on the patients back is an abnormal structure of the body. Further, the abnormal structure is caused by a benign tumor. The requested service will improve function and prevent further inflammation and pain. Accordingly, the requested procedure to remove a mole from the back is reconstructive in natureFinal 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha Sureclick 140 mg/mL. Based on the records provided for review, this patient presents with hyperlipidemia and coronary artery disease status post myocardial infarction. She has a documented intolerance to Praluent and Zetia. The patients LDL cholesterol was 102 mg/dL while on maximum tolerated Crestor at 10 mg per day. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. Repatha has been demonstrated to be effective for patients with heterozygous familial hypercholesterolemia or documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this clinical setting, Repatha has been shown to be safe, effective at significantly lowering LDL cholesterol and is associated with improved cardiovascular outcomes. All told, the Repatha Sureclick 140 mg/mL is medically necessary for treatment of this patients hyperlipidemia and coronary artery disease. 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 cardiovascular disease 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 36-year-old female enrollee has requested mental health outpatient treatment 5 times per week from the said date forward for treatment of her anorexia nervosa, major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that although the patient was clearly in need of ongoing treatment, the therapist failed to provide adequate details to establish the treatment was the least intensive service available likely to be safe and effective for management of her condition. As indicated by the APA guidelines for eating disorders, treatment should include appropriate monitoring of the patients weight, vital signs, and labs however these were not available in the records provided for review. Further, this patients documentation did not identify a history of past hospitalizations or provide details of the patients reported suicidality. In addition, the treatment plan is confusing as the current reported global assessment of functioning (GAF) score was lower than the highest reported GAF score during the preceding year. Without significant progress noted between the dates in question, (which were the only outpatient treatment reports submitted), it is likely this patient could have been adequately treated on a less frequent basis. In fact, it appears the patient has progressed in treatment such that the frequency of visits has decreased. Overall, the multiple visits per week were not medically necessary to closely monitor this patient for suicidality or for compromises in her physiological status related to her eating disorder. For these reasons, the medical necessity for 5 psychotherapy visits per week for management of this patients condition has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets generally accepted guidelines for bariatric surgery based on National Institutes of Health criteria. At issue is whether the duodenal switch procedure is medically necessary for treatment of the patients morbid obesity as opposed to available surgical alternatives. The duodenal switch procedure is a reasonable and appropriate treatment option for morbid obesity in the well selected candidate. It is a standard primary treatment for morbid obesity, and is approved by the American Colleges of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services. Duodenal switch is well-accepted as a safe procedure. Nutritional complications can be seen in both LRYGBP and duodenal switch. The randomized clinical trial by Skroubis, et al., as well as the 2004 study by Rabkin, et al. did not show that duodenal switch was associated with significant perioperative risks and postoperative nutritional complications. According to Skroubis, et al., There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD. The most common deficiencies encountered were of iron and vitamin B12. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl. The Rabkin study concludes, LapDS [duodenal switch] is not associated with broad nutritional deficiencies. Annual laboratory studies, which are required following any type of bariatric operation, appear to be sufficient to identify unfavorable trends. In selected patients, additional iron and calcium supplementation are effective when indicated. Clearly, all patients need to be followed closely and well selected to ensure compliance with lifelong follow-up. Furthermore, the duodenal switch procedure is likely to produce superior results than other procedures in this patient who has a BMI of 53. In general, it is well-accepted that for super obese populations, the duodenal switch affords the greatest weight loss of any weight loss procedure. Additionally, the duodenal switch is more appropriate in patients with joint pain who may require non-steroidal anti-inflammatory drugs (NSAIDs) which is a relative contraindication after LRYGBP. In conclusion, upon detailed review of the available scientific literature, the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for amlodipine-valsartan-hydrochlorothiazide (Exforge) for treatment of the enrollee who has a history of hypertension.Findings: The physician reviewer found there is a lack of support for the requested medication in this clinical setting.  The records do not document an adequate trial, allergy or intolerance to a preferred angiotensin receptor blocker, a preferred diuretic or a preferred calcium channel blocker. Current guidelines for treatment of hypertension do not recommend combination antihypertensive medication such as Exforge over other generic medication in the same antihypertensive class. All told, Exforge is not medically necessary for the treatment of this patients medical condition.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 internal medicine with sub-specialty certification in cardiovascular disease 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 female enrollee has requested laser treatment for treatment of her rosacea.  Findings:  The physician reviewer found that the patient is requesting coverage for treatment of telangiectasias associated with rosacea using laser therapy.  The use of pulse dye laser treatment for telangiectasias is considered to be a cosmetic procedure that is expected to provide little more than minimal improvement to her appearance.  The requested services do not qualify as reconstructive in nature, as the treatment is not expected to correct abnormal body structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.  Treatment of telangiectasias associated with rosacea is not considered to be a medically necessary procedure. Overall, the requested laser treatment is not reconstructive in nature and is not medically necessary for the treatment of this patient.