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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for homocysteine testing. Findings:  Three physician reviewers found that the guidelines of the American College of Cardiology (ACC) do not recommend testing for homocysteine levels. Rather the ACC guidelines recommend use of standard risk factor assessment and standard lipid panels. The C-reactive protein (CRP) was mentioned as a possibly benefit in the asymptomatic individual with other normal risk factors but homocysteine was not mentioned. Studies noted that homocysteine level measurement or treatment with folic acid has not been proven to be of clinical benefit. In addition the patient has established cardiovascular disease and is already under treatment. This patient was not being evaluated for screening purposes. Therefore, homocysteine testing performed was not likely to have been superior over the standard options of evaluating this patient. Final Result: 3 of 3 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 internal medicine with sub-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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage enrollee has requested authorization and coverage for consultation with a plastic surgeon. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested consultation for plastic surgery. According to the records, the patient has generalized skin laxity consistent with the history of massive weight loss. Individuals who undergo massive weight loss will experience some skin laxity. In the absence of clear and compelling documentation of specific signs and symptoms that are clearly related to the excess skin or are health threatening, or cause significant functional disability and have failed to improve despite reasonable attempts at conservative therapy, the requested procedures would not be medically necessary. In this patients case, the submitted records do not include evidence of chronic health problems that have failed reasonable attempts at conservative therapy.  In addition, the records do not include documentation of a series of office notes or photographs. Therefore, plastic surgery consultation for evaluation of the patients medical condition is not medically necessary. With regards to whether or not this patient meets the criteria under the expanded concept of medically necessary reconstructive surgery as defined in California law, the submitted records do not support the patient meets these guidelines. The alleged abnormality does not constitute an abnormal structure of the body. Skin laxity is a normal part of aging and a normal finding in men and women with a history of weight gain and weight loss. Therefore, the requested surgery will not improve function or create a normal appearance to the extent possible. For these reasons, the requested consultation is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested sodium fluoride (NaF-18) PET bone scan (CPT 78815) for evaluation of his prostate cancer.  Findings:  Three physician reviewers found that following a radical prostatectomy for prostate cancer, it is appropriate to obtain sequential prostate-specific antigen levels every six to twelve months for five years.  In cases of progressive increases in prostate-specific antigen levels, further evaluation with radionuclide bone scans, MRI, or other imaging modality may be appropriate.  Conventional bone scans are generally sufficient for the evaluation of this patient population.  However, sodium fluoride (NaF-18) PET bone scans are appropriate as a second-line scanning technique.  There is adequate support in the current medical literature for the requested diagnostic procedure in this patients case.  Per the submitted medical records, there have been questionable findings on prior imaging.  The requested sodium fluoride (NaF-18) PET bone scan is likely to be superior over other available options for the evaluation of this patient.  The requested diagnostic procedure will allow for appropriate treatment planning.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: . The patient has requested authorization and coverage for Orencia. The American College of Rheumatology guideline for the treatment of rheumatoid arthritis does not recommend a target synthetic disease-modifying antirheumatic drugs (DMARD), such as Xeljanz or Rinvoq, over a biologic DMARD, such as Orencia, when adjusting treatment to optimize control of rheumatoid arthritis disease symptoms. Ikeda and colleagues describe the overlap syndrome between rheumatoid arthritis and systemic lupus erythematosus (SLE) as rhupus. The authors report that in a study to assess the efficacy of Orencia for the treatment of rhupus, disease activity as measured by the Clinical Disease Activity Index (CDAI) significantly decreased between baseline and 12 weeks and remained low through 24 weeks when treated with Orencia. The authors further noted that the levels of immunoglobulin G and anti-DNA antibody significantly decreased between baseline and 24 weeks. The authors concluded that Orencia is likely to be efficacious in patients with rhupus who have arthritis refractory to methotrexate and may have a moderate effect in reducing abnormal antibody production in persons with rheumatoid arthritis and SLE overlap syndrome. In this clinical setting, given that current medical literature supports the use of Orencia for the treatment of rheumatoid arthritis with SLE as an overlap syndrome, the requested medication is medically indicated. Therefore, Orencia is medically necessary for the treatment of this patient. 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 rheumatology 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 reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) treatment provided from the date of service in question, forward. Findings:  The physician reviewer found that, in the records provided for review, the patients addictive illness has dominated his daily routine for nearly half of his life and contributed to significant impairment across multiple domains of functionality. He has no reliable sober support group. He has a history of impulsive behavior that placed him, and possibly others, at risk of harm. He has co-occurring psychiatric illness and has struggled with self-defeating perfectionism. He has failed multiple chemical dependency treatment programs in the past while the concurrent use of alprazolam and opiates represents a high-lethality combination. The American Society of Addiction Medicine (ASAM) states that the placement decision is the last step in a multidimensional assessment that guides the variety and intensity of services needed in an individualized treatment plan. Further, the American Psychiatric Publishing Textbook of Substance Abuse Treatment reports improved functionality associated with individuals who complete IOP programming. As of the date of service in question, the patient continued to experience anxiety and the sequelae of his characterological organization and addictive illness. He had not yet consolidated the treatment gains necessary to succeed in an outpatient based treatment program. The IOP treatment was and is reasonably expected to improve the patients condition and prevent a more serious episode of illness via relapse, which in-turn would more than likely place the patient and others at risk, and require a more intensive treatment setting. Thus, the services in dispute are safe, appropriate, and consistent with community standards. For these reasons, the IOP services provided from the date of service in question, forward were and are medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 Mavyret. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1b patients should be treated with Mavyret. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested for Lexapro 10mg  for treatment of his depression and anxiety. Findings:  The physician reviewer found that Schatzberg and Nemeroff, S-citalopram was at least as effective as other widely used antidepressants, and in some clinical trials it has been suggested to be superior to other antidepressants based on modestly greater changes in various depression rating scales, especially in severely depressed patients.  They noted that there are a number of clinical trials comparing S-citalopram with a variety of other antidepressants, including venlafaxine, that suggest S-citalopram may have a faster onset of antidepressant efficacy and modest superiority in the treatment of the severely depressed.  The authors also noted that there is evidence to support the patients assertion that Lexapro is an excellent choice for individuals on numerous medications, noting that there are relatively few reports in the literature of drugdrug interactions involving citalopram or S-citalopram.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program (IOP) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the practice guideline authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases stating that There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment. In this case, the patients substance use disorder was complicated by bipolar illness. The patient was prescribed complex pharmacotherapy with a triad of mood stabilizing medications including olanzapine, lithium and lamotrigine. He was also on gabapentin, which can be helpful for alcohol-related symptoms, and had failed a trial of naltrexone. He was drinking more than two bottles of wine every day while a validated rating scale returned a score consistent with moderately severe depression. Thus, the patients provider recommended IOP treatment. Considering the relevant peer-reviewed literature, current practice guidelines and the clinical documentation submitted for review, the request for IOP level of care is appropriate and reasonably expected to improve the patients condition, bolster relapse prevention efforts and prevent a more serious episode of illness. Final Result: The reviewers 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: Reviewers 1, 2, and 3 are board certified in psychiatry 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: Upheld

The patient has requested authorization and coverage for brand name Butrans patch (buprenorphine transdermal) 20 mcg/hour. This patient has severe neuropathic pain related to a complication from a lumbar sympathetic neurolysis procedure. He has been treated with numerous medications as well as interventional procedures to manage this pain. He has found that the Butrans patch has been the most beneficial pain relief modalities. Per the records, the patient was started on the brand name Butrans patch and subsequently switched to a generic formulation. He later reported to his provider that the generic patch was not as effective as the brand name Butrans patch. The U.S. Food and Drug Administration (FDA) reports that brand name and generic formulations are similar in every parameter. The FDA noted that a generic medicine modeled after a brand-name medicine must perform the same in the body as the brand-name medicine. This standard applies to all generic medicines. A generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and the way it should be used. This patients records do not document that he experienced an allergic reaction or is intolerant to the formulary alternative to the brand name Butrans patch. Given these findings, the requested brand name Butrans patch (buprenorphine transdermal) 20 mcg/hour is not medically necessary for 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 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

A 70-year-old male has requested Narrow Band UVB therapy for treatment of his urticaria pigmentosa/mastocytosis.  Findings:  The physician reviewer found that published works provide evidence that NBUVB phototherapy can be useful for the treatment of urticaria pigmentosa. As noted by Loubevres and colleagues, mastocytosis is a heterogeneous group of conditions characterized by an increased number of mast cells in the skin or, less frequently, in other organs such as the liver, spleen, lymph nodes, bone marrow, lungs and gastrointestinal system. The most common clinical skin forms are urticaria pigmentosa, solitary mastocytoma, diffuse cutaneous mastocytosis and telangiectasia macularis eruptiva perstans. Bunimovich and colleagues noted that treatment of urticaria pigmentosa usually starts with elimination of all things that might trigger histamine release. Cutaneous mastocytosis is treated with topical emollients, topical glucocorticoids, and calcineurin inhibitors. Systemic steroids are occasionally used, mainly for aggressive systemic mastocytosis. To treat cutaneous lesions, psoralen UVA or UVA1 without psoralen have been shown to be effective (Castells, et al). A few reports in the literature, including one study from Prignano and colleagues, provide preliminary evidence that NBUVB is beneficial for treatment of urticaria pigmentosa. Since this patients urticaria pigmentosa had previously responded to NBUVB following failure with various medical therapies, it has been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections. The submitted documentation supports the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. Intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the research, the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. There is sufficient support for the requested services in this clinical setting. Therefore, hyaluronan injections are 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 orthopedic 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 40 hours per week of applied behavioral analysis (ABA) therapy and five (5) hours per week of supervision for treatment of the enrollees autism spectrum disorder.   Three reviewers found thatABA is a behavioral approach with a longstanding history of application with children on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism. In one study, comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning, as well as less aberrant behaviors and social problems, than did the other group. ABA therapy is effective when used intensively, approximately 40 hours per week, to comprehensively address all challenges experienced by children on the spectrum. Less exposure to the prescribed methods is inadequate to provide the necessary structure and intervention. In the case of this patient, she requires intensive one-to-one intervention and supervision to elicit desired responses and promote desired changes in behavior. Thus, based on the current literature as well as plan definitions, the recommended ABA therapy and five (5) hours per week of supervision was and is medically necessary. Final Result: Three reviewers 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:  One reviewer is board certified in pediatrics and pediatric critical care and is actively practicing. Two reviewers are board certified in pediatrics and pediatric neurology and are actively practicing.  All three reviewers are 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.