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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine 4% nasal spray.Medical literature supports that the requested medication is medically necessary. A 2014 double-blind, randomized clinical trial (RCT) to evaluate the efficacy of intra-nasal lidocaine on different types of headache found that after intervention, patients mean base pain scores were significantly lower in the group given intra-nasal lidocaine than in the group given normal saline (placebo). The trial concluded that intra-nasal lidocaine is an efficient method for pain reduction in patients with headache and recommended this method in patients referred to an emergency department (ED) with headache. A 2019 meta-analysis of intra-nasal lidocaine for acute migraine concluded that intra-nasal lidocaine can be considered a useful option for patients with an acute migraine. It yields a high success rate, a low pain intensity, an infrequent need for rescue medicine, and tolerable adverse events.In this case, the patient has a rare mast cell disorder which limits her ability to use many classes of medications to treat her headaches. She has tried and failed common treatments for idiopathic intracranial hypertension and still suffers from intractable headaches. She has also trialed intra-nasal lidocaine spray with significant relief of her headaches, and there is evidence to support this form of treatment in the recent randomized trials and a meta-analysis study. Under these circumstances, the requested lidocaine 4% nasal spray is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Overturned

The enrollee is requesting authorization and coverage surgically assisted rapid palatal expansion with LE FORT 1-2 piece w/o graft. The enrollee has a history of underdevelopment of the bones of the upper jaw, obstructive sleep apnea, and an unusually large tongue. A progress note reported prior treatment had provided minimal improvement in his sleep quality. The enrollee reports his upper palate is too small and his enlarged tongue cannot be positioned properly in his mouth, which affects his breathing, eating, and speech, and causes drooling and destruction of his teeth. Studies report surgically assisted rapid palatal expansion allows for stable skeletal expansion of the upper jaw, with minimal risk of long-term relapse. Transverse deficiency correction through surgically assisted rapid palatal expansion will directly improve airway space, chewing, and speech. In addition, the health of the oral cavity is improved to avoid further injury.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested bilateral breast MRI for evaluation of her breast cancer. Findings:  The physician reviewer found that there are several indications for MRI of the breast, which include a determination of the pre-operative extent of cancer, post-operative residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, the screening of high-risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High-risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High-risk patients also include those with biopsy-proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. For this patient, the procedure was performed to determine the pre-operative extent of her cancer and that is a valid indication for breast MRI.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested plastic surgery for the removal of polymastia for treatment of her polymastia.  Findings:  The physician reviewer found that the requested bilateral axillary mastectomies and Z-plasty procedures are not supported as reconstructive in nature or medically necessary for treatment of this patients medical condition. Although significant breast tissue within the axilla is considered abnormal, this is not demonstrated in the photographs. There is some fullness of the breast in the area of the axilla, but this appears to be within a normal range based on the patients body habitus. Lesavoy and colleagues noted that, aberrant breast tissue is usually present along the milk line above or below the normal breast location. Occasionally, it is found in unusual locations, such as the axilla, scapula, thigh, and labia majora. The abnormal accumulation of breast tissue within the axilla would be considered caused by a developmental abnormality. However, no clear functional deficit has been adequately established. Overall, the medical documentation and photographs do not support that more than a minimal improvement is likely. Therefore, the requested procedures are not reconstructive in nature. Overall, there is inadequate medical documentation that the patient has a functional deficit related to her axillary tissue. There is mention of tenderness with menstrual cycles, but this is not supported in the records. The patients axillary tissue is not likely to cause back pain. The patient indicated that she had lactation in these areas with breastfeeding, but this is not described in the medical documentation. Further, the photographs do not demonstrate the presence of significant excess of axillary tissue likely to cause symptoms or that would warrant resection. As documented by Down and colleagues, axillary tissue can be symptomatic. However, a clear functional deficit related to the axillary tissue has not been established in this patients case. Therefore, the requested procedures are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested coverage for chiropractic/physical therapy treatments beyond the 38 treatments authorized and prospective coverage for continued chiropractic/physical therapy treatment (20 sessions).  The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees moderate to severe right upper back and bilateral lower neck pain.  Findings:  The physician reviewer found that the patient has undergone extensive therapies since her 2009 injury, including various passive palliative interventions for pain relief.  No significant, sustained benefit would be anticipated with further passive treatment such as chiropractic manipulation at this time.  The requested chiropractic therapy is not medically necessary, as there is no proven benefit of long-term chiropractic manipulation treatments on health or functional outcomes in the setting of chronic spinal pain, thoracic outlet syndrome or other musculoskeletal conditions.  Bronfort concluded that the evidence is not conclusive for the long-term efficacy of spinal manipulation for any type of low back pain.  In 2008, Bronfort and colleagues did not note significant, sustained benefit to spinal manipulation and mobilization over other conservative management.  With respect to thoracic outlet syndrome management, the key to management is an accurate diagnosis.  Once the lesion is precisely identified, surgery may be needed to decompress the affected neurological or vascular structure.  There is no proven role, however, of chiropractic manipulation for this condition.In this patients case, the records do not establish any objective benefit that can be clearly attributed to the chiropractic manipulation that has been provided to date and was not a function of the natural history of symptoms in the course of a case of chronic pain.  Overall, no significant benefit would be expected with long-term chiropractic manipulation for this patient over an independent exercise program, relative rest and self-applied palliative modalities.  All told, prior chiropractic/physical therapy treatments beyond the 38 treatments authorized and continued chiropractic/physical therapy treatments (20 sessions) were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee requested mental health residential treatment center (RTC) for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, at the time of admission the patient was completely non-functional.  She had regressed to such a point that she did require 24-hour medical and nursing care. She had already received two years of outpatient psychiatric treatment and several weeks of inpatient treatment. The notes from the end of the disputed time period indicate that progress had been made in ADLs, but much remained to be done. For the reasons provided, the services were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested for intensive outpatient program services for treatment of her eating disorder. Findings:  The physician reviewer found that this is the patients first course of treatment for her eating disorder, it is essential that she not be discharged from services or stepped down in services before it is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested for out-of-network services at UCSF for treatment of the enrollees headaches. Findings:  The physician reviewer found that the indisputable reputation of that staff in headache management, the patients diagnosis and subsequent treatment has not substantially changed from the specialist care she received in-network. While one of the out-of-network providers is an adult (as opposed to pediatric) neurologist, there is no evidence that similar services from an adult neurologist were not available in plan. Furthermore, at this patients age of 15, her treatment going forward can be appropriately managed by an in-network adult neurologist.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a nine-year-old male with speech delay including both an expressive and receptive language delay. He began speech therapy for the speech delay in 1998. At that time he possessed 50 words, but did not use them in spontaneous speech. He was able to follow single stage duration with motoric response and could identify body parts. He showed good progress in language skills. The Health Plan provided coverage for speech therapy until December 2003. The patients parent has requested reimbursement for speech therapy services the patient received through July 2004.Review of the submitted clinical information including the November 2003 and April 2004 treatment goals reveals the patients treatment goals have in fact been advanced. The November 2003 goals indicate the patient will recall information from a paragraph. The April 2004 goals state the patient will recall information from a story. Recall from a paragraph versus a story is in fact different and shows a logical step in goals. The articulation goal is also different, comparing isolated sounds to using sounds in a sentence. Additionally, the daily progress notes reveal the patient was making progress with both the receptive language and articulation goals. The notes do not document achievement of recall in a story, but document 90% recall in a paragraph. The patient did achieve the articulation goal as documented in May 2004.Given that the patients therapist provided appropriate goals and documented gains in these goals, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested acupuncture for treatment of her allergies. Findings:  Three physician reviewers found that the relevant clinical literature includes a study by Roberts and colleagues, in which the authors discussed findings of seven randomized, controlled trials. The authors concluded that, A meta-analysis failed to show any summary benefits of acupuncture treatment for symptom severity scores or serum IgE measures which could not have been accounted for by chance alone. These findings are consistent with the comments by Passalacqua and colleagues, who stated that, Meta-analyses provided no clear evidence for the efficacy of acupuncture in rhinitis and asthma. The authors also reported that, Therapeutic efficacy of complementary-alternative treatments for rhinitis and asthma is not supported by currently available evidence. As such, the clinical records do not document treatment and failure or intolerance of standard, tested therapies in the treatment of allergies. Thus, the submitted records do not demonstrate that acupuncture is likely to be more beneficial for the treatment of this patients allergies than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old male who entered intensive outpatient treatment (IOP) in March 2004 for treatment of oppositional defiant/conduct disorder and polysubstance abuse. The patient continued to receive IOP services until August 2004. The Health Plan indicates IOP services were not medically necessary as of May 2004.The patient clearly has the predominant diagnosis of oppositional defiant/conduct disorder and polysubstance abuse. There is no evidence the intensive outpatient program included psychiatric oversight or treatment monitoring. Given the patients clinical condition at admission, clinical expectations, and his response to the IOP services he had already received, he did not meet medically necessity criteria for continued IOP services as of May 2004. The submitted documentation does not substantiate that the patient was unable to receive treatment in a traditional outpatient setting. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female has requested Herceptin, Aloxi, Epogen and Navelbine for treatment of metastatic breast cancer.  Findings:  The physician reviewer found that the Health Plans denial of Herceptin with Navelbine should be overturned. Although the patient was treated previously with Herceptin, it was essentially a single-agent therapy. Although further study is necessary, there is data supporting Herceptin and Navelbine therapy and this could be considered the patients first Herceptin chemotherapy combination. The denial of Epogen should also be overturned as there is sufficient evidence and nationally accepted guidelines to support its use in this patient. In addition, Aloxi was and is medically necessary for the patient. There sufficient evidence to support the use of Aloxi for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for ForeseeHome AMD Monitoring System.  The enrollee was referred to an ophthalmologist by his primary care physician for a bulging left eye.  Bilateral non-exudative (dry) age-related macular degeneration (AMD) had been diagnosed.   Eye drops, hot compresses, ultraviolet protection, and Ocusoft lid scrubs with pads or foam at night are recommended treatments.  The enrollee reports his vision is worsening.  The ophthalmologist has recommended the ForseeHome AMD Monitoring System, which is an at-home monitoring device for early detection of wet AMD.  Findings:  The physician reviewer found that according to the medical literature, choroidal neovascularization (CNV) is part of the spectrum of age-related macular degeneration, and threatens visual acuity. The ForeseeHome AMD Monitoring System (Notal Vision) monitors for the earliest signs of CNV.  A study proved its efficacy in a controlled clinical trial. Participants in the study were at high risk for developing CNV, with either bilateral large lipid deposits (drusen), in two study eyes; or in one eye (study eye) and advanced AMD in the other (non-study) eye, and best corrected visual acuity of 20/60 or better in the study eye(s). It was concluded early detection with the ForeseeHome AMD Monitoring System increases the ability to provide interventions that will lead to preserved visual acuity, which was significantly better at the time of CNV detection.  Monitoring to detect progression from dry to wet AMD is integral to preserving vision. Early detection, followed by immediate treatment is key to achieving the best possible outcomes. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in ophthalmology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested anterior and posterior L5-S1 fusion for treatment of her mild anterolisthesis at L5-S1.  Findings:  The physician reviewer found that at issue in this case is the medical necessity of an anterior and posterior fusion at L5-S1. In the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified. Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Option 1 would argue against a fusion in this patient as she would be undergoing a primary disc excision at the L5-S1 level. Option 2 is also contraindicated as she does not have evidence of lumbar spinal instability at any level. Although she does have some mild anterolisthesis, there is no radiographic evidence such as a flexion-extension film that the spine is unstable. Option 3 does not apply to this patient as she does not have objective evidence of chronic axial low back pain. Finally, options 4 and 5 do not apply as she does not have evidence of a recurrent disc herniation at L5-S1. Thus, of the five treatment options detailed by Resnick and colleagues, none of them provide support for a lumbar fusion procedure in this patient. Based upon the information set forth above and available data, the requested surgery is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 46-year-old deceased female has requested accessories for the speech generating device associated with the Eye Gaze System for treatment of the enrollees amyotrophic lateral sclerosis. Findings:  The physician reviewer found that an add-on is medically indicated when it is designed to compensate for a specific impairment and enhance the functional independence of that individual. The Tash microlight switch, a device that allows for feather light touch activation, was medically necessary for the patient because it facilitated her communication in the setting of extreme motor weakness. The series 5 wireless compact flash allowed for connection to a wireless network and the XGA display upgrade provided enhanced video graphics. Neither of these two add-ons was adaptive or specifically designed to compensate for impairments secondary to amyotrophic lateral sclerosis.  Thus, the Tash microlight switch was medically indicated for this patient. The series 5 wireless compact flash and service charge for display, XGA were not medically indicated for this patient.