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 an implanted hypoglossal nerve stimulator. Hypoglossal nerve stimulation is a new and emerging technology for the treatment of OSA. While initial studies have shown promise, conclusions cannot be drawn from the evidence to date. Ultimately, these summaries reflect that the current evidence does not permit conclusions regarding efficacy or effective health outcomes on hypoglossal nerve stimulation. Moreover, the optimal patient selection criteria for the use of hypoglossal nerve stimulation has not been defined. All told, the current medical literature and guidelines do not support an implanted hypoglossal stimulation system as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that implanted hypoglossal stimulation system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested service is 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:  One reviewer is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing. One Reviewer is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing.  One Reviewer is board certified in otolaryngology with sub-specialty certification in plastic and reconstructive surgery and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested physical therapy for treatment of the enrollee, who has been diagnosed with global developmental delay. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested therapy.  This patient has multiple medical problems that have rendered him globally developmentally and cognitively delayed.  Based on the documentation provided, while he did not regress over the course of one year while he was receiving physical therapy, he demonstrated no improvements.  He has been tolerating a home physical therapy program.  Ongoing individual physical therapy is not medically necessary because the patient is no longer showing functional gains.  All told, the requested physical therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an additional three hours of weekly direct one-to-one ABA therapy services (eight hours per week total) and reimbursement and prospective authorization and coverage for eight hours of weekly direct one-on-one ABA services going forward.  Findings:  The physician reviewer found that given this patients diagnosis of autism, ABA services are medically necessary to treat his identified deficits. Although the patient has received years of ABA therapy, significant gains have been made, and further goals are still being addressed. The Behavior Analytic Certification Boards (BACB) autism treatment guidelines highlight that continued treatment is dependent upon an individual patients needs. Moreover, there is no identified duration of treatment that has been shown to be the maximum, as ABA is individualized treatment based on each patients unique manifestations within their natural environments. Further supporting ABA in this clinical setting, the National Autism Centers National Standards Project (NSP) has identified that behavioral interventions are the only evidence based treatment backed in the medical literature as effective for patients with autism over 22 years of age. Specifically, the NSP reported that ABA can target the skill areas of communication, self-regulation, personal responsibility, and problem behaviors. As reported in the records provided for review, these areas have been the focus in this patients treatment plan. Overall, the patient has not met all of his treatment goals, as the treatment plan lists several ongoing and new goals. However, the patient continues to make progress on treatment goals as evidenced by the multiple graphs throughout the treatment plan. The additional three hours of weekly direct one-on-one ABA therapy will enable the patient and provider to continue to address the patients behavioral areas of concern. Based on these findings, an additional three hours of weekly direct one-to-one ABA therapy services (eight hours per week total) in the past, and eight hours of weekly direct one-on-one ABA services going forward were and are medically necessary for treatment of this patients autism spectrum disorder.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a board certified psychologist and a board certified behavior analyst 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 55-year-old male who has osteopenia based upon a bone mass density scan performed in 2003. A L5 vertebral wedge fracture was reportedly found in approximately 1999. Preventive treatment with Fosamax and Actonel was attempted, but was discontinued due to gastrointestinal side effects. The patient was started on Miacalcin nasal spray (Miacalcin) without side effects, but with unknown response. He wishes to continue this treatment. The Health Plan has denied reimbursement for Miacalcin on the basis it was not medically necessary.The Health Plans denial should be upheld. There is no data indicating Miacalcin results in fracture prevention for men or women. If there is documented evidence the patient experienced a prior fracture, there are several alternative treatments available that would be appropriate for this patient. There is no evidence Miacalcin was likely to be beneficial in this case. Therefore, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A 45-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient was evaluated in the Emergency Department for right elbow pain that commenced two weeks prior. The pain was located at the medial aspect of the elbow and worsened with range of motion. The patient was diagnosed with tendinitis. At issue in this case is whether a prudent layperson would believe she 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 patient reported that she had experienced the onset of pain two weeks prior to her Emergency department visit. She had not sustained any recent injury. No systemic symptoms were reported. The patient denied any symptoms of a serious health problem, such as redness, fever, swelling or skin changes. Although she had some pain, she had full range of motion without sensory or vascular deficits. The submitted medical record documentation does not demonstrate that the patient was experiencing symptoms that would cause a prudent layperson to believe her health was at serious risk without immediate medical attention. She had not sustained an acute injury and had been experiencing symptoms for two weeks. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an urgent or emergent basis. The patients symptoms on the date of service in question did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health in this clinical situation.  Further, the submitted clinical evidence does not document the presence of severe pain upon presentation to the Emergency Department.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Zepatier 50/100 mg for 12 weeks for treatment of the enrollees hepatitis C virus.Findings: The physician reviewer fount that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including Zepatier for 12 weeks. These guideline recommendations are based on clinical trial results showing a 99% cure rate. For these reasons, treatment with Zepatier 50/100 mg tablets daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 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.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee requested authorization and coverage of the medication Anadrol. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees HIV-related symptoms.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rituxan 720 mg weekly for four doses for treatment of the enrollees anti-muscle specific kinase (MuSK) myasthenia gravis. Findings:  The physician reviewer found that Myasthenia gravis with anti-muscle specific kinase (MuSK) antibodies is known to be more resistant to treatment than myasthenia gravis with acetylcholine receptor binding antibody disease, and is often more symptomatic. Rituxan is recognized to be effective in the treatment of myasthenia gravis, and one recent paper indicated the most effective therapies are corticosteroids, plasma exchange, and Rituximab. This patient currently remains symptomatic on corticosteroids and azathioprine, and previously with IVIG. Rituxan is a reasonable therapy with the plan of tapering down or off of corticosteroids and possibly off azathioprine as well. For these reasons, the requested Rituxan 720 mg weekly for four doses is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested Rituxan 720 mg weekly for four doses is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Upheld

A 56-year-old male enrollee requested an inpatient sleep study test in a center (sleep lab) for medical evaluation of his fatigue.   Findings:  The physician reviewer found that there is no documentation of a sleep medicine history or physical examination. Further, the records lack the patients Epworth sleepiness score, mallampati score, witnessed apnea, awakening gasping, awakening with headaches, daytime hypersomnia, cataplexy, hypnagogic hallucination, sleep paralysis or profound snoring. The patient has a BMI of about 30 and has fatigue. Consistent with the current medical literature, there is insufficient documentation to substantiate the medical necessity of the requested sleep study for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Medtronic bladder control therapy. After behavioral and pharmacologic therapy, the third-line of therapy is PTNS or Botox injection and subsequently InterStim insertion. The American Urologic Association (AUA) treatment guidelines and current literature support a role for this treatment. However, the medical literature does not support PTNS as an ongoing maintenance therapy. Thus, PTNS weekly sessions for 12 weeks is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while maintenance therapy with PTNS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested PTNS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  One reviewer is board certified in urology and is actively practicing. One reviewer is board certified in urology and is actively practicing.  One reviewer is board certified in urology and is 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

The patient is a 46-year-old woman who has a history of treatment resistant depression. The submitted clinical materials indicate she has attempted multiple trials of other medications without relief of her depression. Effexor XR, in a dose larger than that recommended by the manufacturer (450mg per day), has been beneficial for her. The Health Plan has denied coverage for this dosage on the basis that it is not medically necessary.Clinical experience often results in the off-label use of medications or in the use of medications in doses higher than those commonly used. As long as there are positive results for the patient and the patient understands the risks and benefits and consents to such, the proposed dosage is medically reasonable and appropriate. The patient should undergo regular medical monitoring to ensure that the higher dose of Effexor XR continues to be effective and does not cause untoward side effects. Accordingly, I have determined the requested dosage is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for any or all of the intensive outpatient program (IOP) services (including cognitive services such as individual therapy, family therapy and group therapy) provided by La Europa Academy.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm due to a history of regular cannabis use but denied suicidal ideation of self-harm and expressed hope for the future, attachment to life, and a willingness to follow a crisis plan. In terms of functional status, the records support a score of 3. The documentation noted functional impairment prior to admission to the IOP due to struggles with school avoidance and significant conflict with family members. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to a history of significant cannabis use. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due the divorce of her parents, her mothers mental illness, and a peer group that used substances. With regard to level of support of the recovery environment, the records support a score of 3. The records noted limited support due to the patients tense relationship with her mother and her mother not participating in family therapy.In terms of resiliency and treatment history, the records support a score of 3. The patient did not consistently attend outpatient therapy prior to admission to residential treatment and IOP, although the records suggested her recovery was maintained with strong professional support in a structured setting. With regard to treatment acceptance and engagement, the records support a score of 2. The patient engaged in treatment. Thus, the patient has a total score of 19. In this case, the recommended level of care was high intensity community-based services. This is consistent with the level of care that the patient received in the IOP. Therefore, IOP services (including cognitive services such as individual therapy, family therapy and group therapy) provided by La Europa Academy were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested percutaneous peripheral tibial nerve neurostimulation for medical treatment of her medical condition.  Findings:  Three physician reviewers found that percutaneous tibial nerve stimulation is considered an acceptable third-line treatment option for overactive bladder when first-line and second-line options have failed, according to the current American Urological Association guidelines.  However, there is no documentation that first-line treatments have been tried.  The submitted records indicate that only a single second-line treatment that has been tried, oxybutynin chloride.  All told, percutaneous peripheral tibial nerve neurostimulation was not likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee requested substance abuse residential treatment center (RTC) services for treatment of the enrollees alcohol dependence.  Findings:  The physician reviewer found that residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition.  At the time of admission the patient was not acutely intoxicated. He was showing tremor on extension only and some gait disturbance. His vital signs were stable and although he complained of diaphoresis and chills, on evaluation his CIWA was zero. He had no biomedical or psychiatric comorbidity. He denied suicidal ideation, plan and intent and he denied homicidal ideation. There was no psychotic ideation in any modality. He was not a danger to others. He was motivated, willingly entered treatment, and was an active participant in his program from the beginning and throughout his residential stay.  Although he did have relapse issues, he had recognition of these and with prompting would have been able to self-manage. His family was supportive and he had a concerned spouse. He did not meet the American Society of Addiction Medicine (ASAM) criteria for residential level of care. Finally, the patient did not show the presence of active withdrawal symptoms that could not have been safely or effectively managed at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, RTC level of care was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old male enrollee has requested for artificial cervical disc replacement for treatment of his ruptured disc.   Findings:  Two physician reviewers found that There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. TDR has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up.No truly blinded studies have been done to establish efficacy; the results available are short-term at best. Until this is a proven therapy, it cannot be considered to be equivalent or better than standard therapies.