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

Nature of Statutory Criteria/Case Summary: A request was made for reimbursement and prospective authorization and coverage for cognitive behavioral therapy (CBT) utilizing a stress lab (exposure therapy program). The Health Plan has denied the services at issue as not medically necessary.Researchers noted the American Academy of Pediatrics (AAP) clinical practice guideline for patients 6 to 11 years of age recommend prescribing U.S. Food and Drug Administration (FDA) approved medications for ADHD with or without behavior therapy. Researchers reviewed 54 studies that compared nonpharmacologic treatment strategies with placebo, pharmacologic, or another nonpharmacologic treatment. The researchers concluded that despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.The medical record indicates that the patient has primary problems due to his ADHD symptoms. He was noted to be impulsive, fidgety, and had difficulty staying organized. These symptoms are typical of ADHD disorder. Evidence-based treatment of ADHD includes pharmacology with psychotropic medications as well as therapy. CBT can be used for young patients with ADHD to improve coping skills as well as organizational skills. A short period of CBT was appropriate for the patient. However, there is no indication that ongoing CBT is clinically indicated due to the lack of specific symptoms that need to be treated in the progress notes. CBT is typically a short-term therapy and is not administered on an ongoing or indefinite basis. Final Result: The reviewer determined that some of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz XR 11 mg daily. In regards to the use of Xeljanz (tofacitinib) for the treatment of rheumatoid arthritis (RA), the 2015 American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis recommends methotrexate (MTX)+/- TNF inhibitor (TNFi) as the next treatment in those who have failed MTX alone. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe RA. There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. Findings showed that Golimumab reduced the signs and symptoms of rheumatoid arthritis in patients with active disease who had previously received one or more TNF alpha inhibitors. There are currently no studies looking at failure of a first TNFi agent and a different biologic agent. Given safety data and efficacy rates, a second TNFi with or without MTX of non-TNF biologic +/- agent is recommended over Xeljanz.(Singh, et al.). In this case, the patient has failed methotrexate, Humira and meloxicam. It is noted that she has failed one TNFi.  She has not failed a second TNFi or a non-TNF biologic agent as recommended by the 2015 ACR guidelines. At this time, the records fail to demonstrate a contraindication of a second TNFi trial. The literature demonstrates safety and efficacy of TNFi over Xeljanz given the long-term experience with the medication.  The literature fails to demonstrate any head to head trials showing Xeljanz is more effective than a TNFi. As such, the request for Xeljanz is not medically necessaryFinal Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old male enrollee has requested for uvulopalatopharyngoplasty (UPPP), tonsillectomy and glossectomy surgeries for treatment of his sleep apnea.   Findings:  Three physician reviewers found that based on the 2010 sleep study results, this patient does not now have sleep apnea. The patient had apparently lost some weight during the time period between the two sleep studies. This patient had poor sleep architecture, which was caused by a combination of his erratic work schedule and his medications. All told, based on this patients latest sleep study, he does not have sleep apnea. Therefore, in the absence of obstructive sleep apnea, none of the proposed surgeries would be beneficial for this patient (see Goldberg).
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:  Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. All told, the services at issue were likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram is due to improved cancer detection rate.  Final Result: Three 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 reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: 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. including: (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. For dimension 1, a review of the patients records indicates that the patient was not in substantial withdrawal-related distress. There are no significant biomedical conditions or continued substance use reported to satisfy dimension 2. The patient does not meet the criterion for dimension 3, as he has PTSD and depression, but he does not require 24-hour support to control behavioral impulses or substance use. For dimension 4, the patient has expressed a willingness to change. However, he has limited insight regarding his need for continuing care. Dimensions 5 and 6 are met as the records document that the patient continues to endorse addiction symptoms including craving. Further, the patient has expressed that his substance use history has caused a strain on his relationship with his family, leaving him with limited social supports. Based on these 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 subspecialty 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

The patient is a 57-year-old male who was diagnosed psoriatic arthritis (PsA). On 5/16/19, an infectious disease consultation noted that lumbar puncture results did not suggest active Lyme disease. A left knee effusion was noted to be resolved. On 5/20/19, the patient was noted to have a history of left knee Lyme arthritis. He had taken Humira for four to five years but this was stopped due to Lyme arthritis. The provider noted that Humira had been held for six weeks. On 5/20/19, the patients knee pain and swelling were noted to be nearly resolved. The patient reported pain in the right third metacarpophalangeal (MCP) joint and the fifth proximal interphalangeal (PIP) joint. No psoriatic lesions were noted. The physical examination revealed synovitis in the right third PIP joint. Tenderness was noted in the PIP joints. Left knee range of motion was full without pain. The treatment plan included holding stronger immunosuppressant medications due to Lyme disease and starting Otezla as a low risk option. The patient has requested authorization and coverage for Otezla 30 mg tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Otezla 30 mg tablets are medically necessary for the treatment of the patients medical condition. Current medical evidence does not support the requested medication in this clinical setting.  Gossec and colleagues noted recommendations address conventional synthetic disease modifying antirheumatic drugs (csDMARDs) as an initial therapy after failure of nonsteroidal anti-inflammatory drugs (NSAIDs) and local therapy for active disease, followed, if necessary, by a biological disease modifying antirheumatic drug (bDMARD) or a targeted synthetic DMARD (tsDMARD). The first bDMARD would usually be a tumor necrosis factor (TNF) inhibitor. bDMARDs targeting interleukin (IL)12/23 (ustekinumab) or IL-17 pathways (secukinumab) may be used in patients for whom TNF inhibitors are inappropriate and a tsDMARD such as a phosphodiesterase 4-inhibitor (apremilast) if bDMARDs are inappropriate. Haber and colleagues concluded apremilast should be reserved for patients who are unable to take disease-modifying antirheumatic drugs. In this case, the medical records did not demonstrate a failure of or contraindication to NSAIDs and csDMARDs, like methotrexate. These medications have proven safety and efficacy.The physician reviewer found that, Otezla 30 mg tablets are not medically necessary for the treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for otoplasty for the right ear for treatment of the enrollees prominent right ear. Findings:  The physician reviewer found that the request for otoplasty for the right ear is medically necessary for treatment of the patients medical condition. According to American Society of Plastic Surgeons (ASPS) Otoplasty is medically necessary and considered reconstructive surgery when it is performed to approximate a normal appearance, even if it does not improve function. The patient presents with evidence of bilateral prominent ears that are abnormal. Although the right side is not as severe as the left, the right ear is significantly abnormal. This is confirmed by medical examination and photographic review. The patient has a true congenital ear deformity on both sides. The patient lacks antihelical folds on both sides which is abnormal and is a congenital deformity. Thus, surgical correction is clinically indicated to correct a congenital deformity. For the reasons provided, the requested surgery is medically necessary and reconstructive in nature for treatment of the patients right ear deformity.  Final Result: The reviewer determined that the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is 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: Medical Necessity
Decision: Upheld

The parent of a seven-year, six-month-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that there is scant literature evaluating the long-term outcome of speech therapy for non-verbal children with autism. However, the Council on Children with Disabilities (COCWD) documents the need for speech therapy as part of the treatment regimen for children with autism (Myers, et al.). Further, the American Speech-Language-Hearing Association (ASHA) has concluded that low intensity pull-out services are generally ineffective for these patients. Regarding this patient, based on the records provided, he has not demonstrated adequate functional improvement in speech over a one-year period of time. In addition, it is unclear from this patients therapy reports that his receptive language skills have improved. The provider reports that the patient is more cooperative in therapy, but primarily behavioral approaches were used to achieve that level of compliance. All told, the medical necessity of speech therapy is not established by the documentation provided.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that hyaluronic acid injections for osteoarthritic knee pain are an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individual patients. With long-term and widespread use, the injections have been confirmed to be safe without severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can all have serious systemic side effects and may not be reasonable treatment options for some patients. This patient reports consistent relief with hyaluronic acid injections and the medical records confirm these results. Thus, the requested Euflexxa injections are supported as medically necessary for treatment of this patients bilateral knee osteoarthritis. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee requested the medication combination of Sovaldi tablet 400 mg, Pegasys injection 180 mcg/0.5 ml and Ribasphere 200 mg for medical treatment of her hepatitis C virus.  Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medications. Non-invasive testing indicates that she has a high probability of F2 disease. Chopra and Arora indicate that treatment can be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The highest priority patients for treatment include those who are at highest risk of substantial morbidity and mortality from untreated HCV infection, namely those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of HCV infection. Per the AASLD and ISDA guidelines, high priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis, such as a Metavir F2. Given that she has a high probability of F2 disease, the request for the proposed medication combination is medically necessary for treatment of her HCV.
Appeal type: Medical Necessity
Decision: Upheld

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested a shingles vaccine for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate that the patient requires the shingles vaccine.  In a study by Oxman et al, they enrolled 38,546 adults 60 years of age or older in a randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine (zoster vaccine).  The authors found that the zoster vaccine markedly reduced morbidity from herpes zoster and post-herpetic neuralgia among older adults.  In the  Cochrane review, the authors looked at the shingles vaccine and which age group benefitted the most, `Analyses according to age groups indicated a greater benefit in participants aged 60 to 69 years, RR 0.36 (95% CI 0.30 to 0.45) and in participants aged 70 years and over, RR 0.63 (95% CI 0.53 to 0.75).`  The Advisory Committee on Immunization Practices (ACIP) recommends the vaccination for adults who are 60-years-old and over. The Infectious Diseases Society of America (IDSA) recommends that patients who are about to receive immunosuppression should be vaccinated at least 4 weeks before the initiation of immunosuppressive therapy if they do not have a history of zoster vaccination. Although the records state that there is the likelihood of immunosuppression, these records fail to demonstrate that the patient has a diagnosis requiring immunosuppression or definite plans for immunosuppression. As such, the requested shingles vaccine is not medically necessary in this clinical setting.  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 rheumatology and allergy and immunology 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: Urgent Care
Decision: Upheld

A 55-year-old male enrollee has requested emergency services for treatment of his medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.This patients symptoms were not sudden in onset or severe. He reported sore throat and ear pain as well as a rash. The patient specifically denied fever, vomiting, trouble eating or any other symptoms of a more serious or life-threatening nature. He had already started a course of antibiotics. While the patients symptoms warranted a medical evaluation, this service did not need to be provided on an emergent basis. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Accent 1000 with Unity Language loaded, CPT code E2510, with accessories: 84 location key guard, Xtreme case, and strap handle. Findings:  The physician reviewer found that there has been increasing research demonstrating positive patient outcomes with the use of augmentative and alternative communication (AAC) devices by young patients with autism. In addition, recent data demonstrates emerging support for the effectiveness of aided AAC interventions in teaching children with autism. An AAC encompasses various modalities that can replace or augment a patients speech and other existing communication skills. Autistic patients are most likely to benefit, especially those who fail to develop sufficient speech skills for daily functional communication. This patient population is at particular risk of developing problem behaviors, limited academic learning, and poor social networks. This patient was not able to communicate his daily needs with the picture exchange communication system. However, he has demonstrated his ability to communicate his daily needs with the Accent 1000 device. Given the patients success with use of the Accent 1000, and lack of response to other options, the Accent 1000 with Unity Language loaded, CPT code E2510, with accessories: 84 location key guard, Xtreme case, and strap handle, is medically necessary for this patient.Final Result: The reviewer determined that the requested equipment 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.