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

A 40-year-old female enrollee has requested for a total disc replacement with the ProDisc device for treatment of her lower back pain. Findings:  Three physician reviewers found that despite the fact that artificial discs have been implanted for almost 15 years, there is currently insufficient data to adequately assess the performance of total disc replacement.  There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems.  Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented.  Additionally, total disc arthroplasty with the ProDisc device has been associated with substantial morbidity and even mortality.The manuscript from a recently completed randomized, prospective, multicenter study of the ProDisc device versus circumferential fusion for low back pain lacks sufficient detail for independent evaluation of the data to confirm or reject the authors conclusions.  The success measures chosen by the authors yielded far lower numbers of success for either group than expected in the study design, which suggest that the sample sizes from the power analyses were inadequate for a non-inferiority study. This study reported no reliability data. There was no evidence of, or detail provided, regarding the reliability and validity of the novel satisfaction outcome used in the study, or of the pain assessment methods used in the primary outcomes measures. Furthermore, the details needed to follow and evaluate the accuracy of the authors conclusions regarding the definitions of success based upon the 10 outcome measures were not provided. No definitions for what constituted a success for any of the 10 outcomes were provided.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old male with a diagnosis of allergic rhinitis. The submitted information indicates the patient has taken Allegra in the past for seasonal allergy problems with successful results. The patients provider indicates the patient is not contraindicated to Alavert or Claritin, and may use Claritin 10mg daily. There is no history of failure or intolerance to over-the-counter alternatives such as Alavert, Claritin, or generic loratadine.A request has been made for authorization and coverage for Allegra. The Health Plan has denied the request on the basis that Allegra is not medically necessary for treatment of the patients allergic rhinitis.The submitted records do not document the medical necessity of Allegra for treatment of the patients seasonal allergic rhinitis. The patients provider has indicated that Claritin may be used. Furthermore, there is no documented history of failure of over-the-counter alternatives. Although the patient has obtained good results from Allegra, there is no indication the over-the-counter alternatives will be ineffective. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for bioidentical hormone replacement therapy for treatment of her history of breast cancer. Findings:  Three physician reviewers found that women with breast cancer often experience early menopause due to adjuvant chemotherapy, and may have vasomotor symptoms, estrogen therapy should not be prescribed.  In this clinical situation, there is concern regarding increased risk of breast cancer recurrence with estrogen therapy.  The current medical evidence does not support the use of hormone replacement therapy for women with a personal history of breast cancer. This would apply to bioidentical or other female hormones.  All told, the requested bioidentical hormone replacement therapy is not likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old man with knee pain and chondromalacia confirmed by arthroscopy. He has undergone three to four series of Synvisc injections with reportedly good results.  A request has now been made for an additional series of three injections. The Health Plan has denied this request on the basis the requested injections are not medically necessary.There is no documentation in the literature that warrants this extensive use of hyaluronic acid (Synvisc) injections. The patient has already had three to four series of injections. There is no indication or medical justification for an additional series. The patient can also try oral supplements, anti-inflammatory medications, or cortisone injections.  The proposed treatment however, cannot be recommended as medically appropriate.  Therefore, I have determined that the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for residential treatment center services. Review of the medical records indicates the patient has a history of substance abuse, underwent detoxification and was admitted to a residential treatment center. She experienced headaches, anxiety, panic, overeating, fear based thought patterns, avoidance behaviors, anger, depression, fatigue, and difficulty concentrating. She was committed to recovery and trying to develop a sober support system and find a sponsor. She was working on confronting her denial. She had anxiety, cravings, using dreams, worthlessness, depression, insomnia, headache, panic, worries about her finances and her living situation, and maintaining sobriety with her cravings and anxiety. She worked on coping skills, awareness and knowledge of unhealthy dynamics. The medical literature indicates that residential treatment is primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case, the patient was considered in need of 24 hour residential treatment, as she had continued alcohol use, despite negative consequences. She suffered financial and medical consequences and was isolated from friends and family. She still needed 24 hour treatment during this time period. It was not likely that she could remain abstinent outside of a 24 hour therapeutic structured and supervised residential treatment setting in order to work on improving coping skills, identify relapse triggers, and deal with cravings and anxiety. She was started on Naltrexone during this time to better deal with cravings. She came from an inpatient detoxification treatment and required further inpatient treatment to work on these issues and give her the best chance of abstinence. Final Result: The reviewer determined that the requested therapy was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested for inpatient psychiatric hospital services for treatment of her psychosis, NOS. Findings:  The physician reviewer found that she was not at risk to self or others, and her behavior was not out of control. Thus, she could have been treated at a lesser level of care. A review of the treatment records shows that she was increasingly agitated and attempted to hit staff. A note suggests continuing psychosis of a significant degree. The patient continues to act in an aggressive and psychotic manner. She needs very close staff supervision.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was experiencing suicidal thoughts, although without intent or plan.  Her continued suicidal thoughts, especially in the context of a patient with two suicide attempts within the past year, required close monitoring.  She was very depressed, experienced nightmares and tactile hallucinations.  She was felt to be exhibiting posttraumatic stress disorder symptoms, consistent with her history of sexual abuse.  She was started on risperidone and continued to require monitoring for these symptoms.  She no longer was experiencing nightmares or hallucinations.  Therefore, partial hospitalization program services were medically necessary, as she needed monitoring for her symptoms of suicidal thoughts, hallucinations and posttraumatic stress disorder.  She was just started on risperidone and needed to be observed for side effects and effectiveness.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 70-year-old female has requested coverage for past tomographic genotyping provided for evaluation of her pancreatic cysts.  Findings:  Two physician reviewers found that the patient has a history of pancreatic cysts. The patient underwent evaluation with endoscopic ultrasound with fine needle aspiration biopsies of the cysts in the pancreas. The tissue was submitted for DNA analysis with the PathFinderTG. The PathFinder test is an analysis of the DNA of mutations and of the DNA in a cellular population. The PathFinder has been used in patients with cancer of an unknown primary, to identify the tissue of origin of the cancer. In such clinical situations, its use remains controversial, yet has been shown to provide substantial benefit in a limited number of patients. Another use for the PathFinder test is in the analysis of pancreatic cysts, as in this patients case. The PathFinder analysis attempts to determine if the cysts are truly benign or whether they contain elements that more closely resemble a malignant expression. As noted in the peer reviewed medical literature submitted with the appeal, the PathFinder test is considered useful in the analysis of pancreatic cysts for this purpose. For these reasons, the PathFinderTG was likely to be more beneficial for further evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Foundation One genetic testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. The therapy of advanced non-small-cell lung carcinoma (NSCLC) has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas (Pao, et al; Lynch, et al). The mutational landscape of NSCLC has significantly expanded in the past 2-3 years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences (Pao and Girard). It is generally accepted that the panel of mutations typically analyzed in NSCLC are mutually exclusive somatic driver mutations. A study by Von Hoff and colleagues of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Von Hoff, et al). As such, the use of Foundation One gene testing is considered consistent with current standards of care, and was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Two 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 internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy.  Findings:  The physician reviewer found that the use of proton beam radiation therapy is an accepted radiation technology that has proven efficacy and tolerability.  Certain conditions, such as base of skull chordomas and chondrosarcomas and pediatric central nervous system malignancies, are probably best treated with proton beam radiation therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue.  In this patient with an anterior temporal lobe recurrence, it is likely that proton beam radiation therapy would better achieve sparing of the optic nerve and orbit.  While a treatment plan comparison was not provided, it is very difficult to spare these structures when treating an anterior temporal lobe region.  This becomes a particular challenge in patients previously irradiated, as these structures are at risk of injury from cumulative doses in excess of 55-60 Gy.  The sharp dose fall off of proton beam radiation therapy is therefore advantageous in this clinical setting.  In this patients case, proton beam radiation therapy was likely to have been superior over other treatment options.  Final Result: The reviewers determined that the services at issue were 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 reviewer 1, 2 & 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee requested authorization and coverage of acupuncture for treatment of back pain and acne.  The health plan authorized six acupuncture treatments for the enrollees back pain, but denied authorization and coverage for acupuncture treatment of the enrollees acne indicating the requested acupuncture is not medically necessary.One acupuncture reviewer performed a medical necessity Independent Medical Review.  The acupuncture reviewer upheld the health plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee is diagnosed with major depressive disorder (MDD). On 1/6/19, his patient health questionnaire (PHQ-9) score was 16. On 1/9/19, the patients generalized anxiety disorder (GAD-7) score was 16. On 1/15/19, the patients provider noted deterioration in the patients mood. The patient was noted to be more tearful, especially with social discomfort. The patient demonstrated an increase in obsessive thoughts, reduced motivation associated with decreased frequency in his activities of daily living, and is isolating himself from others. The patient reported a depressed mood and hopelessness. At issue in this case is whether individual outpatient psychotherapy once a week is medically necessary for the treatment of this patients medical condition. The National Institute for Health and Clinical Excellence reports that psychotherapy is an evidence-based treatment for MDD, either alone or in combination with psychiatric medication management. The aim of treatment is to obtain significant improvement or remission. The duration of treatment may be reduced if remission has been achieved or increased when a patient is making progress. In one study, after treatment with psychotherapy, 62% of patients no longer met the criteria for MDD. Further, the American Psychiatric Association reports that use of a depression-focused psychotherapy is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder. Patients receiving psychotherapy should be carefully and systematically monitored on a regular basis to assess their response to treatment and assess patient safety. When determining the frequency of psychotherapy sessions for an individual patient, the provider should consider multiple factors, including the specific type and goals of psychotherapy, symptom severity, co-occurring disorders, cooperation with treatment, availability of social supports, and the frequency of visits necessary to create and maintain a therapeutic relationship, ensure treatment adherence, and monitor and address depressive symptoms and suicide risk. This patient reported an increase in depressive and anxiety symptoms. The patients provider noted the patient had been stable and responding to weekly therapy, but deteriorated due to the change in frequency of psychotherapy. The medical evidence supports the requested treatment in this clinical setting. Therefore, individual outpatient psychotherapy once a week 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 psychiatry with expertise in psychosomatic 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: The patient has requested authorization and coverage for bilateral breast reduction mammoplasty.Cabral and colleagues state, Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction.According to the American Society of Plastic Surgeons (ASPS), reduction mammaplasty may be recommended based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: chronic breast pain due to weight of the breasts; intertrigo unresponsive to medical management; upper back, neck, and shoulder pain; backache, unspecified; thoracic kyphosis, acquired; shoulder grooving from bra straps; upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area; headache; and/or congenital breast deformity.In this case, the patient reports back, shoulder and neck pain with shoulder grooving. She does not report chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Under these circumstances, the requested bilateral breast reduction mammoplasty is medically necessary to treat this patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, breast hypertrophy is an abnormal structure of the body caused by a developmental abnormality. The patient reports severe neck and back pain, and the requested breast reduction is to improve function by relieving this pain. Accordingly, the requested bilateral breast reduction mammoplasty is reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery 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.