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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided for treatment of the enrollees alcohol dependence and severe depression. Findings:  The physician reviewer found that the records document that this patient had mild post-acute withdrawals of anxiety and insomnia. He was not a danger to himself or others and there were no emotional, behavioral, cognitive, or impulsive symptoms to warrant further residential services. His hypertension was controlled with medications and psychiatrically he could have been managed at a lower level of care. He was motivated and engaged in treatment, his cravings were at a minimum and he had sober supports in place including friends in Alcoholics Anonymous. His recovery could have continued an ambulatory basis in a less restrictive treatment setting. 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 psychiatry with sub-specialty certification 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: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine without contrast (CPT 72148) for evaluation of her chronic low back pain.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient does not have absent reflex, muscular weakness or atrophy. Although she has some change in symptoms since her previous MRI, there is no contraindication to the patient undergoing a course of physical therapy prior to approval of a repeat MRI scan.  Therefore, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested a bronchial thermoplasty for treatment of his asthma.  Findings:  Two physician reviewers found that to date, three trials of bronchial thermoplasty have been completed and each demonstrated improved symptom control after the procedure was completed. The AIR trial examined 112 subjects with moderate to severe asthma and demonstrated improved control over the course of the one year follow-up (Pavord, et al.). The RISA study examined the safety of thermoplasty and found short-term worsening in symptoms, but evidence of improved long-term control of asthma (Cox, et al.). Finally, the AIR2 trial compared thermoplasty with a sham procedure and followed the patients for one year (Castro, et al.). The patients in this study differed from earlier studies because the patients had milder asthma symptoms with fewer patients on oral corticosteroids. The thermoplasty group in AIR2 had fewer exacerbations and improved quality of life when compared to the sham group. However, neither the AIR nor RISA trial demographics indicate whether patients were on medications other than steroids and bronchodilators. By contrast, in the AIR2 trial, 30% of the patients in the thermoplasty group were concurrently being treated with other controlling agents with fewer patients on oral corticosteroids. While there is increasing evidence suggesting bronchial thermoplasty can be beneficial for patients with severe and uncontrolled asthma, the procedure is only indicated for patients who have failed to respond to adequate attempts at conservative therapies. Prior to consideration of bronchial thermoplasty, there should be objective documentation of trial and failure of an aggressive medication regimen including such agents as leukotriene receptor antagonists, methylxanthines, omalizumab or anticholinergics. In this case, although there is evidence the patient has severe asthma, the medical records provided do not document adequate attempts at an aggressive and closely monitored outpatient regimen. As such, there is insufficient clinical evidence demonstrating the patient is an appropriate candidate for bronchial thermoplasty to warrant performance of the procedure at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested for proton beam radiation therapy for treatment of his larynx cancer. Findings:  Three physician reviewers found that there is sufficient outcome data from well-controlled, randomized, peer-reviewed studies involving large numbers of patients which demonstrates that proton beam therapy is likely to result in a better outcome for this patient than standard modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested enhanced external counterpulsation for the treatment of his multiple cardiac problems. Findings:  Two physician reviewers found that the use of enhanced external counterpulsation (EECP) in chronic angina patients who cannot be safely re-vascularized and are refractory to medications is accepted as a medically appropriate treatment modality. The current American College of Cardiology (ACC) guidelines for the treatment of chronic angina specifically consider the use of EECP in this patient population. The ACC classification of this recommendation for EECP recognizes that the indications for the use of EECP are still being studied. Gibbons and colleagues found in their study that EECP was generally well tolerated and efficacious with approximately 75% to 80% of patients reporting improvement in symptoms. However, additional clinical trial data are necessary before this technology can be recommended definitively. Given this, the current recommendations for treatment of angina remain anti-anginal therapy or re-vascularization as first line therapy, with EECP reserved for those symptomatic patients who fail a reasonable trial of medications and cannot be re-vascularized. In this particular case, this patient is on several anti-anginal agents including one from each drug class. He was taking a beta blocker, long-acting nitrate, calcium channel blocker, and Ranexa, which amount to maximal medical therapy. Further, the documentation provided indicates that the patient, at that time, could not be re-vascularized. Specifically, the patient had a surgical consultation and the diagonal area was thought to be jailed. As such, this patient had refractory symptoms of chest pain or angina. EECP is normally considered in this subset of patient that experiences continued Class 3 to 4 angina despite maximal medical therapy, and is not a candidate for re-vascularization.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for proton beam therapy (PBT) in a high dose of 60 Gy in 28 fractions (CPT 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387). The records provided for review document that this patient presents with a history of a carotid body tumor. The patients provider has recommended treatment with PBT. Currently, there is a lack of meaningful clinical data to support the routine use of PBT in the treatment of patients with head and neck cancers or paragangliomas. Furthermore, there is a paucity of published randomized trials that support the use of PBT over treatment with intensity modulated radiation therapy (IMRT) with photons. Per the National Comprehensive Cancer Network (NCCN) guidelines, carotid body tumors should be treated with photons using radiosurgery or fractionated with IMRT, which are associated with low risk of complications. Baxi and colleagues reported that PBT should further improve the conformality of head and neck irradiation, but there are limited actual clinical data and no phase III studies currently supporting their superiority to IMRT with regard to actual clinical outcomes in patients with head and neck cancer. All told, the requested PBT in a high dose of 60 Gy in 28 fractions (CPT 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387) is not medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested artificial disc replacement for the treatment of his degenerative disc disease at L5-S1. Findings:  Three physician reviewers found that artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though short-term results have been favorable, further studies and results are needed. Thus, the procedure cannot be recommended at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested the prescription medication Celebrex for treatment of her spastic paraparesis. Findings:  The physician reviewer found that this patient has had progressive spasticity and pain due to diagnosed HSP. Numerous medications have been tried to manage her disruptive symptomatology. A combination of medications addressing spasticity, mood, fatigue and pain has been found most effective. Celebrex has been used successfully in this patient with good tolerance and improved pain control. However, there is no documentation in the submitted records of a trial of other NSAID medications. Therefore, the Health Plans denial should be upheld at this time. At least two other NSAID medications in lieu of Celebrex should be tried over a one-month period while other medications remain unchanged. If there is lessened pain control or if GI side effects are noted on the other NSAIDS, then Celebrex should be authorized by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested continued use of a power wheelchair for treatment of his history of chronic pain. Findings:  The physician reviewer found that per the medical records, physical examinations have noted some tenderness in the patients limbs and edema in the legs.  However, there have been no documented impairments in the limbs, trunk, cardiovascular system, respiratory system or other relevant organ systems that would preclude the use of a cane or manual wheelchair to accomplish his mobility-related activities of daily living. The statements in the providers letter on the specified date are based on subjective complaints and the patients self-reported ability to walk.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed in the community by a physical therapist and noted to be able to ambulate in the indoor and outdoor household setting with a cane.  A power mobility device was being used for community mobility.  Overall, the records from the patients physicians and the specialized mobility evaluation in the community do not support the medical necessity of ongoing use of a power mobility device such as a power wheelchair.  All told, continued use of a power wheelchair is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical preparation of graft side of trunk by excision of scar (CPT code 15002), with the approved surgery to repair trunk (CPT 13101 and 13102).  Findings:  The physician reviewer found that the patient complained of severe pain and tension in the pubic area resulting in back pain. The patient reported a rash that was treated successfully with medication and improved hygiene. The enrollee reported flattening of the mons pubis area and distortion of the labia. The provider noted that the panniculectomy scars could be revised and relieve some tension from the mons pubis. The provider stated the patient could benefit from excision of the vertical abdominal scar and recreation of the umbilicus.Under California law, reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or create a normal appearance, to the extent possible. If the surgery is intended to create a normal appearance, it must offer more than a minimal improvement in appearance. California law also defines cosmetic surgery as surgery that is performed to alter or reshape normal structures of the body in order to improve appearance. California law mandates that health plans must cover reconstructive surgery but are not required to cover cosmetic surgery. The documentation provided for review does not include evidence of complaints of pain or loss of function from the scar. Moreover, the proposed recreation of the umbilicus would not be reconstructive in nature. The proposed procedure is not for correction of any physical symptom and would be performed solely to enhance the patients appearance in the absence of any signs or symptoms of functional abnormalities. The clinical documentation and photographs demonstrate that this patient has a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. All told, the requested surgical preparation of graft side of trunk by excision of scar (CPT code 15002) is not medically necessary or reconstructive in nature for 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 board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the allergen specific IgG test for medical evaluation of her metabolic disorder.   Findings:  Three physician reviewers found that testing for food sensitivities by any one of multiple methodologies including radioallergosorbent (RAST) testing, skin testing, or measurement of serum IgG and IgE has not proven to be useful in this clinical setting. Moreover, this patients provider did not document concern for an allergic gastrointestinal disease such as eosinophilic gastroenteritis or eosinophilic esophagitis, which may have been an indication for testing. Thus, the allergen specific IgG test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested for a duodenal switch for treatment of her morbid obesity. Findings:  The physician reviewer found that the submitted clinical information demonstrates that the patient meets generally accepted guidelines for bariatric surgery based on National Institutes of Health criteria. There is no evidence of dietary or behavioral health contraindications to surgery. 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 the Centers for Medicare and Medicaid Services. The duodenal switch has been shown to be safe and efficacious with excellent long-term outcomes based on 10-year follow-up data. Furthermore, the procedure has been shown to have the best resolution for weight related co-morbid conditions as well as the best weight loss of any surgical procedure.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 20-year-old male who has been struggling with severe refractory headaches for over five years. He has been seen by numerous headache specialists around the country. The patient has failed treatment with 17 preventative  medications, 14 acute or abortive therapies and a variety of non-pharmacologic therapies as well. He is  currently followed by a pain specialist who has recommended a trial of Lyrica beginning at a dose of 300mg per day. The patients request for reimbursement and continued authorization and coverage of Lyrica was denied by the Health Plan citing a lack of medical necessity.The patients headaches are severe and unquestionably refractory to standard treatment modalities as numerous pharmacological and non-pharmacologic therapies have been tried and failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at dosages up to 300mg twice per day. Lyrica should be approved on a trial basis with medically supervised titration until either therapeutic success or failure is demonstrated. If treatment with Lyrica is beneficial and without untoward side effects, authorization should be continued.Based upon the information set forth above, I have determined the medication at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential alcohol use disorder treatment services for treatment of the enrollees alcohol use disorder. Findings:  The physician reviewer found that this patients records do not include a psychiatric evaluation, daily notes, medication administration records, individual therapy notes, nursing notes, vital signs, or Clinical Institute Withdrawal Assessment (CIWA) scores. The patient was medically stable and psychiatrically stable to the extent that she did not require treatment in a 24-hour facility. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care in a less restrictive treatment setting. She has had multiple prior treatments at residential but not at intensive outpatient program (IOP) or partial hospitalization program (PHP) levels of care. Further, there is a lack of evidence to suggest that she was unlikely to respond to a lower level of care. Overall, she did not meet the American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care and could have been successfully treated at an ambulatory level of care such as PHP or IOP with concomitant sober living. 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 psychiatry with sub-specialty certification 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuous treatment of Harvoni for 24 weeks for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition. In the ION-2 study, 440 HCV patients underwent randomization and were treated, 20% had cirrhosis and 79% had HCV genotype 1a infection. The rates of sustained virologic response were high in all treatment groups. There was a 99% (95% confidence interval (CI), (95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and 99% (95% CI, 95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and ribavirin. The results of an abstract were presented at the American Association for the Study of Liver Diseases Liver Meeting. In this double-blind study, Bourliere and colleagues randomized 155 patients previously unable to achieve a sustained virologic response after sequential treatment with a peginterferon and ribavirin regimen followed by a protease-inhibitor (PI), peginterferon  and ribavirin regimen. The patients underwent treatment with ledipasvir/sofosbuvir and ribavirin placebo for 24 weeks or matching placebo for 12 weeks, followed by ledipasvir/sofosbuvir and ribavirin for 12 weeks. Patients were stratified by HCV subtype and their responses to their most recent therapy. Of the 77 patients treated with ledipasvir/sofosbuvir and ribavirin for 12 weeks, 4% experienced relapse; compared with 3% of the 77 patients treated with ledipasvir/sofosbuvir for 24 weeks, for a 3% total incidence of relapse. Based on the peer-reviewed literature, Harvoni for 24 weeks is medically necessary in this clinical setting. Final Result: The reviewer determined that the requested medication duration 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 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.