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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Aimovig autoinjector. In the current peer-reviewed medical literature, Weatherall noted that chronic migraine is a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. This patients records document 15-20 migraines per month despite treatment with rizatriptan, sumatriptan, Tylenol, Excedrin, Advil and Topamax. However, the patient reported excellent results with Aimovig with a decrease to only two to three migraines per month. Goadsby and colleagues concluded that Aimovig administered subcutaneously at a monthly dose of 70 mg or 140 mg significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months. There is documentation that this patient has failed three migraine prophylactic treatments over the course of three years. Moreover, there is an adequate scientific and medical basis for the utility of the Aimovig autoinjector in this clinical setting. Given this support, the Aimovig autoinjector is medically necessary for treatment of this patients migraine headaches.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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested 40 hours per week applied behavioral analysis (ABA) for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the documentation submitted for review indicates that the patient has behavioral issues that include elopement and self-injury in the school setting. There is research showing that behavioral health treatments including ABA are effective for addressing these behaviors. Thus, ABA services are clinically indicated. ABA is a prescribed set of skills that need to be taught in order to have functional communication and social interaction. These skills sets are broken down into smaller parts and then are taught at the lowest level needed for each patient. These skill sets are designed to remediate the core problems of the autism spectrum disorders. In this case, the patient needs ABA services in the school setting to address behaviors specifically self-injury, elopement and safety issues. However, the requested additional 20 hours of ABA services are not indicated. In this case, an additional seven hours of ABA services rendered in the school setting is clinically indicated. As such, 27 hours per week direct intensive of ABA is medically necessary for treatment of the patients autism.  Final Result: Two reviewers determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

A 43-year-old male enrollee has requested the Real Time Continuous Glucose Monitoring device and transmitter for the treatment of his diabetes. Findings:  The physician reviewer found that continuous glucose monitoring systems (CGMS) are now accepted and recommended by informed health care providers that specialize in diabetes management.  There is evidence in the literature about the benefits of CGMS in adults and children, and the device is accepted in the medical community that specializes in management of diabetes.  The device is used in the management of the patient's medical condition, and there is no equivalent alternative. Therefore, the Real Time Continuous Glucose Monitoring device and transmitter are medically indicated for this patient with brittle, long-standing type 1 diabetes complicated by frequent hypoglycemic events. This equipment can alert the patient when a severe glucose excursion occurs during the unattended gaps, which may be asymptomatic and not detected by his standard hand-held monitor. The requested equipment will prevent the patient from progressing into a life-threatening condition, such as hypoglycemic coma or diabetes ketoacidosis. In the long-term, the CGMS might be able to better control this patients diabetes mellitus and prevent diabetes-related complications.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for her current methadone maintenance treatment program (methadone 210 mg daily and take home level). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. This patient has been stable on her methadone maintenance treatment program and is able to function in her activities of daily living. There is no indication of diversion or use of other drugs of abuse. There is no indication of overdose or using other medications that may interact with the methadone. The Centers for Disease Control and Prevention opioid prescribing guidelines specifically state that the new guidelines are not meant for opiate maintenance programs. The effectiveness of methadone to prevent relapse to addiction is well-proven. All told, the patients current methadone maintenance treatment program (methadone 210 mg daily and take home level) is medically necessary for the treatment of this patient. 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 anesthesiology with sub-specialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services.The medical literature supports that the requested services are medically necessary. Researchers performed data analysis of randomized controlled trials and concluded that acupuncture appears to be a promising therapeutic approach for cervical vertigo. Authors conducted a randomized control trial to evaluate the effectiveness of a multimodal approach to the management of cervical vertigo. They concluded that the multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability. Chiu and colleagues conducted a controlled clinical trial involving 60 participants and concluded that acupuncture demonstrates a significant immediate effect in reducing discomforts of both dizziness and vertigo. In this case, the patient has right ear pain and dizziness and has a history of vertigo that has been relieved by treatment with acupuncture. The patient has requested acupuncture treatment for vertigo at this time, and this treatment is supported in the medical literature. Accordingly, the requested acupuncture services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is licensed in acupuncture, with board certification in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that in managing patients with chronic HCV, denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on HCV does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. For the reasons provided, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients HCV. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 29-year-old male enrollee has requested residential treatment his polysubstance dependence.  Findings:  The physician reviewer found that residential treatment was not medically necessary during the said timeframe according to current standards of evidence-based practice and expert consensus. The patient did not show any behavioral issues which required 24-hour supervision.  There were no withdrawal symptoms or serious medical complications requiring residential treatment.  His last use of medication was 10 days prior to admission.  The admitting assessment describes the patient as being very motivated, and the clinical records indicate that he was attentive and participated actively in the program. Given the fact that he tried propofol, partial hospitalization program services would have been a clinically appropriate alternative for this patient during the dates of service at issue.   Residential treatment was not indicated according to American Society of Addiction Medicine Patient Placement Criteria or American Psychiatric Association practice guidelines.
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 the American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the due to the advantages it brings radiologists interpreting mammograms especially in cases of extremely or heterogeneously dense tissue such as in this case. Tomosynthesis often allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only.   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

A forty-eight year-old female with chronic mouth pain is requesting authorization for a 10-week course of therapy recommended by the patients acupuncture provider.  The patient has had the mouth pain since the surgical removal of a tumor.Reviewers Findings:The reviewing physician found that in the clinical records of acupuncture therapy there is no reference to mouth pain with the exception of a note wherein the patient complained of mouth and jaw pain.  Also, the acupuncture providers notes do not indicate improvement or worsening of symptoms.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. Findings:  The physician reviewer found that At issue in this case is whether the TMS services to treat the patients mental health or substance use disorder are medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.TMS is indicated for severe, recurrent MDD that has not responded to traditional medication and psychotherapy treatment. In this case, TMS had worked to improve patient functioning, allowing her to return to work, and with decreased suicidal ideation. The records show that the patients psychiatrist described partial remission with the 36 sessions. The last five sessions were done bilaterally to adjust for the patients residual symptoms with some improvement. Since TMS was terminated, the patient has reported worsened depressive symptoms and suicidal ideation. Although full remission was not achieved, the patient did have improvement from treatment and would benefit from additional sessions. Further, the patient has reported worsening of symptoms since termination of TMS over a month ago. For these reasons, TMS services are medically necessary for treatment of this patient.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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus.  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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline 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 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, treatment with Sovaldi and ribavirin is medically necessary for treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil for treatment of the enrollee, who has a history of obstructive sleep apneal. Findings:  The physician reviewer found that current practice guidelines from the American Academy of Sleep Medicine indicate that modafinil is only used in OSA patients when the underlying OSA has been addressed, Modafinil is recommended for the treatment of residual excessive daytime sleepiness in OSA patients who have sleepiness despite effective PAP treatment and who are lacking any other identifiable cause for their sleepiness. This statement was reaffirmed in subsequent guidelines. In this case, the patient reported that he uses the CPAP less than one hour per night.  It is unknown if his OSA has been successfully treated by another methodology (e.g. oral appliance therapy). The clinical studies that were conducted on modafinil for OSA only evaluated this medication in patients with treated OSA. While modafinil is known to have wake-promoting properties, current medical literature does not permit conclusions on its overall efficacy in untreated OSA, at this time. Consequently, given the lack of documented adequate treatment of this patients OSA, the medical necessity for the requested medication has not been established. Therefore, modafinil is 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. Credentials/Qualifications: The reviewer is board certified in in neurology with sub-specialty certification in sleep 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Whole Exome Genomic Sequencing Reanalysis Testing (CPT 81417).Findings: Three out of three physician reviewers found that the requested Whole Exome Genomic Sequencing Reanalysis Testing (CPT 81417) is likely to be more beneficial than any other available standard therapy for the patients condition.Wright and colleagues state that analysis of whole exome sequencing has rapidly become not only acceptable, but essential in identifying underlying genetic conditions, especially in children. Extensive medical literature supports this process. The number of identified genes and pathogenic variants recognized to be associated with human disease is growing exponentially (Wright, C., et al.). Wenger and colleagues conducted a study of 40 individuals with previously non-diagnostic exome, and they found a diagnosis in 4 of these individuals (10%). For each of these individuals, the publication that allowed for diagnosis was published within one year of the initial negative exome report, and for one individual, the gene was published one month after the initial non-diagnostic exome (Wenger, A., et al.). Ewans and colleagues conducted a study published one year later which also found an additional 11% diagnosis rate (from a cohort of 54 patients) when reanalysis was performed only one year after an initial non-diagnostic exome. Wright and colleagues conducted a study that showed an increase in diagnostic rate from 27% to 40% (an increase of 13%) with reanalysis of non-diagnostic exome from a cohort of 1,133 children with neurodevelopmental disorders (Wright, C., et al.).In this case, the patient has a medical history of developmental delay, autism, dysmorphic features, seizures, and language regression. Prior to exome sequencing, the patient had normal fragile X testing, a normal microarray, and normal MECP2 testing. She initially underwent whole exome sequencing five years ago, with no pathogenic variants in genes associated with her symptoms found at the time. Since the cause of the patients symptoms is still unknown and unsolved, a reanalysis of her exome data would be appropriate to identify underlying genetic conditions. Thus, the requested Whole Exome Genomic Sequencing Reanalysis Testing (CPT 81417) is likely to be more beneficial than any other available standard therapy for the patients condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard therapy for the patients condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested Xifaxan (rifaximin)for treatment of his small intestinal bowel overgrowth (SIBO).    Findings:  The physician reviewer found that based on review of the available records, not testing for SIBO with glucose or Lactulose breath test was reasonable given this patients clinical history. However, the patient should first be treated with an adequate trial of more standard, proven antibiotic agents prior to use of Xifaxan. In the medical literature, medications such as tetracycline, metronidazole, ampicillin, and TMP/SMX have all been shown to be effective for treatment of SIBO. Since the patient has no documented allergies to any of these drugs, the use of Xifaxan is not medically necessary in this patients care and was appropriately denied.