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

The patient is a 33-year-old female who is 58 tall and weighs 280 pounds with a body mass index (BMI) of 44.1. She is requesting authorization for a consultation with a bariatric surgeon. The patient has a multitude of comorbid conditions compounding her morbid obesity. She has a history of multiple attempts at weight loss including physically supervised plans as well as plan of diet. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. With a BMI of 44 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. The patient needs to be evaluated by a bariatric surgeon to determine whether the patient should proceed with weight loss surgery. A consultation with a bariatric surgeon is medically indicated and medically necessary for evaluation of this patients morbid obesity. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient does not meet the National Institutes of Health (NIH) consensus criteria for clinically severe obesity. Although the FDA has expanded the inclusion criteria of the laparoscopic gastric band (Lap-Band) to include patients with a BMI of 35-40 without any co-morbid conditions, there are no developed standard guidelines to determine the medical necessity in these patients. The extension of the FDA guidelines allows surgeons to place the Lap-Band in patients with a low BMI without an off-label indication. However, the FDA requires patients with a BMI of 30-35 to document serious weight related co-morbid conditions, which is not included in this patients records. Specifically, this patient does not meet these criteria with a BMI less than 35 and no serious co-morbid conditions. In addition, there is no documentation of failed supervised weight loss within the patients recent medical records or a TSH level to rule out treatable metabolic causes of obesity. For these reasons, the medical necessity of the requested surgery has not been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for iStent Trabecular Micro-Bypass Stent. The patient demonstrates the findings typically seen in patients with early glaucoma. The provider noted that the patient has shown some issues with medication compliance. The provider has recommended intervention with the iStent procedure. On review of the current peer-reviewed medical literature, there is data that the iStent has been found to be a safe and effective treatment modality for this patients ocular hypertension with improvement in intraocular pressure (IOP). Malvankar-Mehta and colleagues noted that, Both iStent implantation with concurrent phacoemulsification and phacoemulsification alone result in a significant decrease in IOP and topical glaucoma medications. However, the authors concluded that, In terms of both reductions, iStent with phacoemulsification significantly outperforms phacoemulsification alone. Therefore, the requested iStent Trabecular Micro-Bypass Stent is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested services are 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Farxiga 5 mg tablets for treatment of the enrollee, who has been diagnosed with diabetes. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Farxiga is a member of a relatively new class of diabetes medications, subtype 2 sodium-glucose transport protein (SGLT2) inhibitors.  The primary mechanism of action of this group of agents involves decreasing renal glucose reabsorption, which results in enhanced urinary glucose excretion, thereby leading to reductions in plasma glucose and hemoglobin A1C concentrations.  Studies have shown glycemic control benefits, weight reduction, and systolic blood pressure lowering with monotherapy as well as in combination with other anti-hyperglycemic agents.  Many providers are currently prescribing SGLT2 inhibitors for diabetic patients, and it has been recommended by numerous medical organizations as part of a recommended regimen for treatment of diabetes.  While this patient may benefit from treatment with a medication from this class of drugs, there is a lack of evidence which supports the benefit of Farxiga over another SGLT2 inhibitor.  It is medically appropriate that this patient first try a formulary alternative.  All told, Farxiga 5 mg tablets are not medically indicated 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 3-year-old male enrollee has requested social skills group therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that ABA therapy was introduced by Lovass in the 1970s. Multiple peer-reviewed controlled studies have established that ABA is the mainstay treatment for autistic children. However, variations in therapeutic approaches have evolved over the years. Some approaches may utilize a highly structured program (discrete trial) (Myers, et al.) while other approaches are less rigid and less structured. These less structured operant training ABA programs are referred to by various names including Incidental Teaching, Natural Language Paradigm, Milieu Teaching, and the Denver Model - all of which follow the childs lead in initiating learning events. There are conflicting opinions about the merits of the various ABA approaches. To date, there is inadequate evidence demonstrating that a single program is superior to any other program. While this patients parents report the patient showed significant improvement in the 6 month treatment program at the specified facility, there is no evidence such gains would not have been achievable in an ABA program that utilized a different approach. Thus, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested microprocessor-controlled lower-limb prosthesis repair for the treatment of her transfemoral amputation. Findings:  Two physician reviewers found that the available scientific studies demonstrates that there is sufficient published evidence that the microprocessor controlled C-leg offers advantages over standard prosthetic devices. For example, a study by Kaufman, et al. found that transfemoral amputees had a significant improvement in balance and gait when using a microprocessor-controlled knee. An article by Orendurff, et al. showed that patients using the C-Leg had greater efficiency at self-selected walking speeds. Furthermore, the study by Seymour, et al. determined that the use of the C-Leg resulted in statistically significant decrease in oxygen consumption, decreased number of steps to complete the same ambulation tasks (i.e., increased functional mobility), and improved quality of life scores compared with non-microprocessor prostheses.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested authorization and coverage for relationship development intervention therapy. The requested service, relationship development intervention therapy, is not medically necessary for this patient. As noted in the medical literature by, Relationship Development Intervention (RDI) is a family-based, behavioral treatment designed to address autisms core symptoms. The author noted that dynamic intelligence is key to improving quality of life for individuals with autism. However, there currently is a paucity of clinical studies demonstrating the effectiveness of RDI therapy. By contrast, there have been numerous case controlled studies demonstrating the effectiveness of ABA therapy in patients with autism spectrum disorder. All told, the requested relationship development intervention therapy is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics and 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

The parent of a 16-year-old female enrollee has requested wireless capsule endoscopy for evaluation of the enrollee, who has a history of ulcerative colitis. Findings:  Three physician reviewers found that in this case, wireless capsule endoscopy was not likely to have been of greater benefit than other tools for evaluating this patient. Based upon the clinical history, endoscopic reports and MRI enterography report, it is unlikely that the patient had a small bowel source of gastrointestinal bleeding or inflammatory bowel disease of the small bowel. The MRI enterography is an excellent study for small bowel Crohns disease, and it is unlikely that the MRI enterography would have missed inflamed bowel. In this clinical scenario, a wireless capsule endoscopy was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested deep brain stimulation for treatment of his medical condition status post intracranial hemorrhage and cognitive deficits.  Findings:  Three physician reviewers found that there is no indication for deep brain stimulation in this case. The risks of this procedure outweigh any expected benefit. The use of DBS is currently being evaluated and there are insufficient controlled studies demonstrating its benefit or safety for patients such as the one documented in this case. Most of the studies demonstrated considerable improvements with the interventions, but their low strength of evidence limits the validity of these findings (Oliveira, L. and Fregni). Based on the lack of scientific evidence demonstrating the equivalence or superiority of DBS compared to standard therapies in treatment of this patients medical condition, the requested therapy is not likely to provide additional benefits.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the evaluation of the enrollee, who presented for an annual breast screening examination. Findings: All three physician reviewers found that the patient underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional digital breast tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination.  The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  The breast sonogram noted multiple bilateral sub-centimeter breast cysts.  Her breast tissue was described as being extremely dense. The Health Plan has denied reimbursement for digital breast tomosynthesis used.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue has been described as being heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For these reasons, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are 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 63-year-old woman with a several year history of migraine headaches. She wishes to receive 18 Axert tablets per month. The submitted notes indicate the patient is currently taking a long list of medications for treatment of migraine headaches. The patient uses Axert as a recovery medication. She has requested authorization for 18 tablets of Axert per month to treat her migraines. The Health Plan has denied the patients request on the basis that the requested prescription is not medically necessary.Acute migraine headaches are generally treated with a variety of medications with triptans being the most effective. For patients who experience frequent migraine attacks, prophylactic medication is essential. Medications such as atenolol are very effective in the prophylactic treatment of migraine. A note from the patients provider in December 2003 indicates that atenolol reduced the patients headaches. Triptans such as Axert should only be used for occasional acute episodes. Upon review of the submitted information, it appears the patients use of multiple medications may be precipitating headaches. Thus, the requested prescription is not medically indicated since it is likely to cause rebound headaches. The patients long list of medications should be reviewed by her provider to determine which medications are essential.Based upon the information set forth above, I have determined that the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested Nexium for treatment of his gastroesophageal reflux disease.  Findings:  The physician reviewer found that the patient has symptomatic GERD which is currently responsive to Nexium. The medical literature suggests that a trial of 6-8 weeks of lansoprazole 30 mg and, if needed, pantoprazole 40 mg are reasonable generic alternatives. Given the records provided for review, there is inadequate documentation that the patient has received an adequate trial of either of these medications. Therefore, the requested Nexium is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-eight year-old female with a diagnosis of major depression is requesting authorization for vagus nerve stimulation (VNS) therapy.  Reviewers Findings:The reviewing physician found that the efficacy of VNS therapy remains unproven and it cannot be considered medically necessary for treatment of the patients medical condition.  The reviewer found that the Health Plan denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services provided. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. 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.The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with the abdominal pain that had been persistent and accompanied by vomiting. The patient underwent diagnostic testing with an EKG and cardiac biomarkers to rule out an acute coronary syndrome, as abdominal pain may represent an angina equivalent. Due to the patients prior abdominal surgery, a CT scan was obtained to rule out bowel obstruction. Given the patients symptoms of ongoing and persistent abdominal pain with vomiting, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date in question. Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Credentials/Qualifications: Physician reviewer number two 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: Overturned

A 51-year-old female enrollee has requested for an osseointegrated auditory implant for treatment of her sensorineural hearing loss. Findings:  The physician reviewer found that an osseointegrated implant is indicated for use in patients with hearing loss who cannot tolerate the use of conventional amplification. In the past, this has frequently been interpreted to mean patients with hearing loss that have external or middle ear disease that precludes the use of traditional hearing aids. Over the years, the application of this device has been expanded to assist patients with severe unilateral sensorineural hearing loss. Given the current literature and standard of care, this patient does meet medical necessity criteria for this device. With the severity of her hearing loss, conventional amplification would not be useful.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve neurostimulator.Multiple studies have demonstrated hypoglossal nerve stimulation can improve health outcomes for patients with obstructive sleep apnea (OSA). Researchers reported on the ADHERE Registry, which is a multicenter prospective observational study to establish long-term outcomes in patients treated with upper airway stimulation. The researchers reported that across their multi-institutional study, upper airway stimulation therapy continues to show significant improvement in subjective and objective OSA symptoms. A meta-analysis by researchers demonstrated clinically significant decreases in observed mean apnea/hypopnea index (AHI) and Epworth Sleepiness Scale combined with improvements in quality of life scales. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with positive pressure therapy. This patient with OSA has an AHI of 56.5 and body mass index (BMI) of 29.6 kg/m2. The provider documented that the patient failed treatment with continuous positive airway pressure (CPAP). There was no evidence of complete concentric collapse at the nasopharynx, velopharynx, or soft palate on drug induced sleep endoscopy (DISE). All told, the requested implantation of a hypoglossal nerve neurostimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested implantation of a hypoglossal nerve neurostimulator is 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 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: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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.