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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Botox injection for treatment of her migraines. The physician reviewer found that the records indicate that this patient has chronic headaches, but there is inadequate documentation to support a diagnosis of chronic migraine. Given the patients medications including Vicodin and Fiorinal, it is likely that she has medication overuse headache. However, the patients use of Vicodin and Fiorinal are not specified in the records provided for review to establish whether her headaches are due to medication overuse. In addition, there is a lack of documentation of an adequate trial with preventive therapies, or the use of triptan. Given these findings, the requested Botox is not medically necessary for treatment of this patients headaches. Final Result: The reviewer determined that the requested therapy 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that this patients depression is treatment-resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the clinical studies, Schutter and colleagues reported that TMS resulted in a moderate effect on treatment-resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Further, Avery and colleagues provides evidence that TMS is a safe and effective treatment for major depressive disorder. Thus, TMS is an effective treatment as demonstrated in the referenced evidence-based literature, has been granted a category I CPT code by the AMA and is FDA approved for the treatment of treatment-resistant major depressive disorder. As this patient has failed numerous standard medical therapies for treatment of major depressive disorder and has had positive results with TMS, the therapy at issue is likely to be more beneficial for treatment of her condition than any available standard modality and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continuous positive airway pressure (CPAP) equipment for treatment of her medical condition.   Findings:  The physician reviewer found that there is a lack of support for the requested equipment in this patients case.  There is no documentation that this patient has obstructive sleep apnea.  Also, daytime hypersomnia is a cornerstone of a diagnosis of suspected obstructive sleep apnea, and her Epworth Sleepiness score was normal.  All told, the requested CPAP is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested growth hormone therapy with Genotropin for treatment of the enrollees idiopathic short stature and type I diabetes.  Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines indicate that a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet these criteria. The patients pre-treatment height was not more than two SDs below normal for age and gender. In addition, his pre-treatment growth velocity was normal, results of screening growth factors were normal, peak GH response on provocative GH testing was normal, and the patient is not known to have a defect in his pituitary gland. The most likely cause of his mild delay in bone age is constitutional delay of growth. All told, the patient does not meet the medical necessity criteria for GH deficiency.
Appeal type: Medical Necessity
Decision: Upheld

A twenty-four year-old female with a history of an eating disorder is requesting coverage of psychiatric treatment services.  Reviewers Findings:The reviewing physician found that treatment at a less intensive level of care then what the patient was receiving would have been appropriate during the period at issue.  The physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autonomic testing for evaluation of her autonomic impairment. Findings:  Two physician reviewers found that in this case, the patient had a non-specific collection of symptoms that were potentially suggestive of an autonomic disorder (dizziness and nocturnal hypotension and constant sensation of being cold).  These symptoms raised suspicion for the possibility of an autonomic disorder. As noted by researchers, the goals of autonomic testing is to help the clinician diagnose the presence of dysautonomia, its distribution and severity, and since they are quantitative, whether it is getting better or worse. Goal number one is to evaluate the severity and distribution of sudomotor, cardiovagal, and adrenergic function using non-invasive quantitative tests. The techniques used in this patients case (tilt-table testing, heart rate variability and Valsalva maneuver evolution), are noted by researchers, to confirm that a specific autonomic function is affected and when other systems are intact. In this patients case, the performance of such testing provided the clinician an evaluation and autonomic etiology for the patients symptoms. Moreover, the testing modalities used in this patients case have also been validated within technology reviews performed by the American Academy of Neurology and are otherwise supported for use within general clinical practice. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for laparoscopic ablation of uterine fibroids. The enrollee has uterine fibroids. Testing showed four fibroids. The enrollees physician reports the enrollee has chronic menorrhagia, which has resulted in chronic iron-deficiency anemia. She has chronic fatigue as a result of the anemia. The enrollees physician is requesting the Acessa procedure to improve the enrollees quality of life. Candidates for myolysis are limited to women with fewer than four fibroids, with the largest being less than 10 centimeters in diameter. A professional society practice bulletin contains no recommendations regarding myolysis as an alternative to hysterectomy in the management of fibroids. The gold standard technique for fibroid treatment remains hysterectomy, although myomectomy may be considered the gold standard for a uterine-sparing procedure. Literature shows ablation is appropriate when there is evidence the enrollee has multiple indications for the procedure, including the enrollee wanting uterine-conserving treatment, as well as being premenopausal. Based on the gap noted in dates of her recent menses, this enrollee is likely perimenopausal.Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gynecology 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested continued Avastin therapy for treatment of colorectal cancer.  Findings:  Three physician reviewers found that Avastin has not been studied as a single agent, as a maintenance therapy or as an adjunct to a 5-FU regimen in patients who are resistant to 5-FU. There is no data to indicate that Avastin is effective as a single agent in either primary or maintenance therapy.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for emergency room services provided. Findings:  The physician reviewer found that California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. In this case, the patient presented with pain in the  gums for two days. The patient rated pain at 5/10. The patient denied difficulty swallowing and no trismus was noted. There was no documentation of difficulty breathing. Final Result: The reviewers determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer is board certified in emergency 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 64-year-old male enrollee has requested for Lyrica 75mg for treatment of her leg pain and back pain. Findings:  The physician reviewer found that recent systematic reviews recommend a treatment algorithm for any neuropathic pain syndrome, regardless of etiology, with the drugs of first choice being tricyclic antidepressants, gabapentin or pregabalin (Lyrica), and opioids. However, these papers acknowledge the limitation that most of their conclusions are drawn from randomized trials in patients with diabetic neuropathy and postherpetic neuralgia. Extrapolation to neuropathic pain of other etiologies is unproven. In a large unpublished pharmaceutical industry study by Remmers and colleagues, pregabalin did not reduce chronic lumbar radicular pain, in contrast to similarly designed studies of pregabalin in diabetic neuropathy and postherpetic neuralgia.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Effexor XR 75 mg. Findings:  The physician reviewer found that venlafaxine is a dual-acting medication that enhances both noradrenergic and serotonergic tone in the central nervous system. The medication has U.S. Food and Drug Administration (FDA) approval for the treatment of major depressive disorder, generalized anxiety disorder, panic disorder and social anxiety disorder. Considering the biological nature of this life-long, recurrent illness, pharmacotherapy is a primary treatment modality for major depressive disorder. In this case, the patient has been clinically stable for years on an evidence-based antidepressant medication endorsed by current practice guidelines and community standards. The patient previously failed a trial of generic venlafaxine. According to a study, the possibility exists that differences in potency may underlie adverse changes in clinical status, when a brand name medicine is substituted with a generic, or if there is a switch between specific generic manufacturers, which represents a reasonable explanation for this patients experience. Subjecting a euthymic and otherwise stable patient to a medication change to demonstrate clinical failure unnecessarily heightens the risk of morbidity. The patient has been prescribed Effexor, which is a safe and appropriate pharmacotherapy that is consistent with good medical practice and is reasonably expected to maintain her clinical stability and prevent an exacerbation of illness. 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 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

The patient is a 22-year-old obese female with gallstones and generalized abdominal pain in the upper and lower abdomen. There is no clear documentation of her pain characteristics or of the pain in relation to eating. The patient is a candidate for bariatric surgery and is on a waiting list for the procedure. Based on the evidence provided, there has been no further workup of her pain except for one general surgical consultation, which indicated possible irritable bowel syndrome. A second opinion consultation was scheduled, but the appointment was not kept. The submitted records do not show elevation of her alkaline phosphatase or bilirubin levels. There is no evidence of a HIDA scan and no documentation to indicate acute cholecystitis.The patient has requested authorization and coverage for a cholecystectomy. The Health Plan has denied this request on the basis that the procedure is not medically necessary at this time.Based on the findings above, there is insufficient evidence that the patient has symptomatic gallstones warranting surgical intervention at this time. Furthermore, since the patient is planning to undergo weight loss surgery, it would be preferable to wait until the bariatric procedure to undergo removal of the gallbladder in order to avoid an additional operation and the adhesions that could complicate the primary bariatric procedure. Given the limited information available regarding the patients symptomatology, she should undergo a second opinion consultation including a HIDA scan. There is insufficient evidence demonstrating that a cholecystectomy is medically warranted at this time.For the reasons set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Mavyret 100-40 mg three tablets daily for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg three tablets daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The ENDURANCE-1 trial showed that eight weeks of treatment was effective. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret 100-40 mg, three tablets daily, for eight 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: Upheld

The parent of a 17-year-old male enrollee has requested  cochlear implant for treatment of the enrollees sensorineural hearing loss. Findings:  The physician reviewer found that this patient has a history of congenital hearing loss with no speech development. A cochlear implant will not help this patient with speech understanding as the medical literature suggests that he is not an ideal candidate to learn speech given his age (Gifford). He has some hearing in the low frequencies and will be able to have sound awareness and can hear sounds including a car horn and train with use of a hearing aid. Given the lack of an indication for the cochlear implants, the requested device is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying CALOCUS guidelines, this patient meets the criteria for IOP services. The patient has demonstrated significant risk of harm (score 3) due to his history of two prior suicide attempts, as well as impulsivity. The patient has shown moderate functional impairment (score 3) considering his recent stabilization achieved while in treatment. The patient has significant comorbidities given his cannabis use and attempt to conceal use during participation in IOP. The patients recovery environment has been mildly stressful (score 2) due to reported anxiety about school performance. The patients recovery environment has been highly supportive (score 1) as his parents have been actively involved his treatment planning and there are adequate family resources to assist the patient is in his recovery. The patient has exhibited moderate response to treatment (score 3). The records report that the patient has been treated in two prior hospitalizations and his improved mood after residential treatment. The patient has been non-collaborative in treatment (score 4) as he has refused to participate in treatment and has been described as disruptive in group therapy. This gives the patient a composite score of 19, which is consistent with high intensity community based services, such as IOP. Per CALOCUS, minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. This patients progress for his condition has been slowly evolving, due to longstanding difficulties and two hospitalizations. The patient started the IOP in December 2019 and he has not completed two months of treatment. Based on these findings, he continues to qualify for the IOP level of care. Accordingly, the IOP services were and are medically necessary for treatment of this patient.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 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.