Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cytogenic microarray testing for evaluation of enrollee who presented at eight weeks with a nonviable pregnancy.Findings: Three physician reviewers found that the American College of Obstetricians and Gynecologists (ACOG) does not recommend routinely assessing chromosomal microarray analysis because there is insufficient evidence to support its use. There are special circumstances when this analysis has been found to be useful. For example, this analysis has been found to be useful when structural abnormalities have been identified on ultrasound.  Of note, this analysis has been noted to be deficient in identifying triploidies of which partial moles are included. In this patients case, the early fetal demise could be sufficiently examined with routine chromosomal analysis. Therefore, the cytogenic microarray testing performed was not likely to have been superior to the standard options for the evaluation of this patient.Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in obstetrics and gynecology 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: Urgent Care
Decision: Upheld

A 39-year-old male enrollee has requested a CT of the pelvis and abdomen on an emergent basis for evaluation of his left lower abdominal pain. 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 patient had been experiencing abdominal pain for three to four days. His pain was not related to acute trauma. He had no other symptoms of acute illness, such as fever or vomiting. The only laboratory abnormalities noted were minimally elevated liver transaminases. This is a nonspecific finding for which a CT scan is not indicated. While the patients symptoms may have warranted a medical evaluation, there was no indication for a CT scan to be obtained on an emergent basis. The patients symptoms on the date of service in question did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis and Viagra for treatment of the enrollees malignant neoplasm of the bladder with erectile dysfunction.Findings:  The physician reviewer found that patients who undergo radical cystoprostatectomy are at high risk of developing erectile dysfunction secondary to damage to the nerves associated with erectile function. Therefore, these patients do have organic basis for erectile dysfunction. The treatment of erectile dysfunction is multimodal. Recovery of sexual function can take up to 12 months. Medical therapy for erectile dysfunction including PDE 5 inhibitors can be beneficial. Cialis daily at a lower dose at 5 mg is approved for treatment of patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. However, this patients records do not document a diagnosis of BPH and his complaints focus on urinary retention. He has undergone a bladder replacement therapy. Thus, his urinary symptoms are related to poorly functioning neobladder rather than bladder outlet obstruction. Final Result: The reviewer determined that the requested medications 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 17-year-old male with a diagnosis of schizoaffective disorder. He was admitted to acute inpatient psychiatric care in May 2006. He had failed attempts with traditional medications and was started on Clozaril after he became acutely psychotic and was determined to be a danger to others. The Clozaril induction went well with the Health Plan authorizing continued inpatient services until May 2006, at which time they felt he could be managed at a lesser level of care. The records reveal that on the day of the non-authorization the patient had an elevated blood pressure and a tremor. Both of these side effects were thought to be an adjustment to the Clozaril medication. The attending physician continued to lower and then discontinued the Seroquel and started propranolol. The patients blood pressure came under control with the tremor decreasing. In May 2006 the patient was discharged to a less intense level of care.At issue is whether inpatient psychiatric services were medically necessary beyond May 2006.The progress notes and physician notes document that the patient was responding to Clozaril and was less sedated with improvement in his psychotic thought process. The increase in blood pressure on the day of the non-authorization was a concern with the attending psychiatrist as evidenced by the progress notes, which stated there was a need to continue to monitor the patient at the inpatient level of care. The attending psychiatrist did not feel that a PHP could adequately monitor the patient at that point in time. The patient stabilized and was discharged in May 2006. The submitted records demonstrate continued care was necessary beyond May 2006 due to the medical necessity of 24/7 monitoring by medical and nursing staff. As such, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested authorization and coverage of the prescription drug evista in the treatment of estrogen replacement.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested denervation of sacroiliac joint for treatment of his medical condition. Findings:  Two physician reviewers found that SI joint pain is a well-documented syndrome with symptoms including low back, buttock and thigh pain and sometimes sciatic-like radiating pain. Along with conservative measures like anti-inflammatories, heat, ice and some manipulation, SI joint injections have shown merit in regards to fluoroscopic guidance with local and steroid with inter-articular placement of the medication. In this case, the patient has had a number of interventions, with the provider looking for the source of this patients pain. Multiple therapies have been tried with little success. Treatment with SI joint injections has provided this patient with significant pain relief. Although the studies above are limited in terms of double-blinded studies, this patient continues to have pain even after a number of interventions. As such, the request for denervation of sacroiliac joint is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two 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:  All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned

A 54-year-old female enrollee has requested total ankle arthroplasty for treatment of her severe post-traumatic arthritis/degenerative joint disease.   Findings:  Two physician reviewers found that unfortunately, this young patient has developed endstage ankle arthritis. Conservative care has been most thorough including viscosupplementation, activity modification and traditional injections. Despite these treatments, the patients symptoms and findings persist. Total ankle arthroplasty has been recommended. The ODG guidelines indicate that earlier studies of ankle arthroplasty in the 1970s and 1980s had high long-term failure rates. Clearly, total ankle arthroplasty has continued to evolve and improve. Surgical techniques have improved. Per the ODG guidelines, the main alternative for total ankle replacement is arthrodesis. At issue in this case is whether total ankle arthroplasty is likely to be more beneficial than available standard therapy which would refer to arthrodesis.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for patients with migraine headaches, there is sufficient peer reviewed medical literature to support its use for patients with refractory headaches. A portion of the data provided demonstrates the safety and efficacy of Botox in patients who have failed standard therapies. In this particular case, the patient has failed numerous medications including first-line abortive and preventative therapies. In addition, she has a documented response to Botox.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stretta procedure. This patient presents with a history of GERD and a hiatal hernia as well as erosive esophagitis. There are several contraindications to Stretta including hiatal hernia larger than 2 cm, achalasia or incomplete LES relaxation in response to swallow. This patients hernia is documented to be 3-4 cm, which is considered a contraindication for the Stretta procedure. There have been multiple studies evaluating the short- and long-term efficacy of the Stretta procedure. Lee and Chang discussed the mechanism of Stretta, which utilizes radiofrequency energy to the lower esophageal sphincter (LES) and gastric cardia to improve symptoms of gastroesophageal reflux. Stretta has been shown to be effective at improving heartburn scores and quality of life in multiple randomized, controlled trials as well as non-randomized prospective trials for up to 12 months (Arts, et al.). However, a recent meta-analysis on the safety and efficacy of Stretta demonstrated no benefit over placebo (Lipka, et al.). Moreover, the ACG guidelines do not endorse treatment with Stretta for patients in the management of GERD (Katz, et al.). All told, the requested Stretta procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested Stretta procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for 60-minute speech therapy sessions twice a week. Researchers reported that the results from 17 studies support the use of high-tech alternative augmentative communication devices to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. The records provided for review establish that the current speech therapy services are successfully incorporating oral motor work, LAMP, and PROMPT approaches to improve this patients speech and language skills. Documentation by the providers report that the patient has been making good progress using these techniques. The LAMP device is the patients main form of communication. To remove access to ongoing therapy using the LAMP device would remove the patients primary mean of communication and lead to frustration and lack of developmental progress. Moreover, the records suggest that these services have not been available to the patient within the Health Plan. All told, the 60-minute speech therapy sessions twice a week 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 neurology with special qualification in child 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed axial tomography (CAT) scan for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that based on the records provided, this patient has significant coronary risk but no documented symptoms or findings of coronary disease.  In this circumstance, guidelines for the evaluation and management of coronary risk are available, periodically updated and endorsed by several national organizations.  These guidelines currently do not recommend routine screening with cardiac CAT scan for calcification scoring.  Cardiac outcomes have not been demonstrated to improve with the routine use of cardiac CAT scanning incremental to that achievable based on therapy guided by a combination of clinical profile and basic lipid analysis.  Routine screening cardiac CAT scanning is not considered standard accepted practice in the medical community in this setting.  Therefore, the requested CAT scan is not likely to be superior over other methods of evaluating this patient.Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested intraoperative radiation therapy for treatment of her left breast invasive ductal carcinoma.  Findings:  Two physician reviewers found that from the most recent National Comprehensive Cancer Network (NCCN) guidelines, candidates for APBI are 60 or older, not BRCA positive, with resected unifocal T1N0, ER positive, infiltrating ductal carcinoma. The guidelines do not recommend intraoperative radiation therapy. The NCCN guidelines state that dose fractionation regimens other than 34 Gy (brachytherapy) in 10 fractions or 38.5 Gy (external beam radiation) in 10 fractions are still being studied. All told, the requested intraoperative radiation therapy is not supported as likely to be more beneficial for treatment of this patients medical condition than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

This case involves a 39-year-old female who carries the diagnoses of chronic pelvic pain, neuropathy, endometriosis and bipolar disorder. She has been treated with danazol, opiates, and anti-seizure medications; the latter was used to treat the patients neuropathy. Apparently, the patient is unable to tolerate the opiates or Neurontin due to her bipolar disorder. Currently, she and her providers believe that Lidoderm patches offer her the only option for pain relief. The Health Plan does not consider Lidoderm patches medically necessary for this patients condition.The treatment of chronic pelvic pain is complex and often requires a multidisciplinary approach and a departure from more conventional therapies. Although Lidoderm is only FDA approved for post-herpetic neuralgia, its use in the treatment of chronic pelvic pain is not without precedent.  Additionally, Lidoderm is currently being used for treatment of other types of chronic pain, such as low back pain and osteoarthritis. Furthermore, it appears no viable alternative to the Lidoderm patch has been proposed in this case. Lidoderm patches appear to be the only effective option for this patient at this time. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medications Farxiga and Trulicity. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees type II diabetes. There is a lack of support in the medical literature for the medical necessity of the requested medications in this clinical setting. As such, the request for Farxiga is not medically necessary because the alternative formulary medication Jardiance is available for treatment of this patient. With regards to the medication Trulicity, the medical necessity for this medication has not been demonstrated in this patients case.  Trulicity is a receptor agonist, which is an incretin, and should not be taken at the same time with another incretin, inhibitor. Trulicity can be an effective next step therapy for this patient because of its effect on weight and glucose levels. Trulicity would be medically indicated. However, based on the documentation as well as the literature, Trulicity is not medically necessary for treatment of this patients medical condition at this time. Final Result: The reviewer determined that the requested medications 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 endocrinology and metabolism. 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

The parents of a twelve year-old female with frequent secondary generalized refractory seizures are requesting authorization of magnetoencephalography (MEG).   Reviewers Findings:  Two of the three reviewing physicians found that MEG, in this clinical setting, may provide useful information not available by other methods.  The third physician found that there are inadequate scientific studies establishing the unequivocal value of MEG in the evaluation or treatment of patients with epilepsy.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar Gel 80 units daily for 10 days.The submitted documentation supports that the requested medication is medically necessary. In this case, the patient has relapsing remitting multiple sclerosis. The patient has acute exacerbation of disease with severe fatigue, balance impairment and weakness. It is reported to be difficult for the patient to go to an inpatient facility to receive IV steroids. The use of H.P. Acthar Gel is indicated under such conditions where the patient is not able to tolerate steroids or transport to an inpatient facility poses a barrier. Under these circumstances, the requested medication, H.P. Acthar Gel 80 units daily for 10 days, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.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.