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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injection (J0585). The Health Plan has denied this request indicating that the medication at issue was medically necessary for treatment of the enrollees medical condition.Findings: There is support in the medical literature for the medication at issue in this clinical setting. Botox is a neurotoxin that causes local muscle weakness through interference acetylcholine release and it has been shown to be effective for treating patients with cervical dystonia.  Botox has been compared to oral drugs like trihexyphenidyl and has been shown to be effective. Botox is considered to be the first line therapy for patients with focal dystonia including cervical dystonia and has been shown to improve pain and morbidity. This patient reported that his Botox treatment provided pain relief. For these reasons, Botox injection (J0585) provided was medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the medication at issue was 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

A 20-year-old female enrollee requested a five day inpatient stay for ketamine infusion for medical treatment of her complex regional pain syndrome (CRPS).  Findings:  Three physician reviewers found that given the unanswered issues including optimal duration and dosing of ketamine infusions, effectiveness of the setting for the infusion (inpatient versus outpatient), and ketamine usage in diagnosed refractory cases of CRPS, the requested ketamine infusion over a five day inpatient admission is not likely to provide this patient with greater benefits than standard available therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested manipulation of the spine under anesthesia for treatment of her back pain.  Findings:  Three physician reviewers found that manipulation under anesthesia (MUA) has no proven benefit on analgesic, health or functional outcomes in the management of spinal or musculoskeletal pain. As stated in the Chiropractic Quality Assurance and Practice Parameters (`The Mercy Document,`) the efficacy of MUA is equivocal, meaning that the benefits of the procedure are not clearly established. Further, there is no proven superior benefit of MUA with respect to health or functional outcomes in comparison to a conservative therapy program including pharmaceutical management, self-applied modalities and a committed self-directed exercise program. Thus, although there are anecdotal evidence including case reports and case series suggesting the functional benefits of MUA over standard treatments, there is inadequate scientific data demonstrating that the potential benefits of the procedure outweigh the risks of the procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene test. Findings:  The physician reviewer found that he pathology report did not document any high risk features such as ulceration. The recommendation for treatment of a stage 1A melanoma is to perform a wide local excision. The DecisionDx Melanoma is used to estimate risk of recurrence and was reported as Class 1A for this patient. Based on the test, the patient has the lowest risk of recurrence at five years. However, per Swetter and colleagues, routine molecular testing including gene expression profiling (GEP) with DecisionDx-Melanoma for prognostication is discouraged until better use criteria are defined. Per the NCCN, the currently available prognostic molecular techniques should not replace pathologic staging procedures. Given that this patients melanoma is superficial without high-risk features, additional testing with DecisionDx-Melanoma was not likely to be more beneficial than standard risk profiling. Given these findings, the DecisionDx-Melanoma gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

The parent of a 16-year-old male enrollee has requested  for a central auditory processing disorder (CAPD) evaluation for evaluation of the enrollees hearing problems. Findings:  The physician reviewer found that the results of the patients auditory evaluation seem to suggest educational/developmental issues other than auditory dysfunction. While there is some evidence of difficulty hearing in competing background noise, there are several other concerns that appear to be less auditory in nature. As such, there was no clear-cut medical indication for the referral for CAPD testing
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested authorization and coverage for Provigil, 200 mg oral tablet for treatment of the enrollees multiple sclerosis.  Findings:  The physician reviewer found that Provigil is widely used in the treatment of patients with fatigue secondary to MS. In the treatment of fatigue, most MS specialists concur that this medication has a role in treatment of some MS patients. There have been multiple studies that have confirmed a clinical benefit in some patients. Use of Provigil for the treatment of MS related fatigue is a reasonable alternative to manage this patients fatigue associated with MS. For these reasons, the requested Provigil is clinically indicated and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued skilled nursing facility (SNF) care including physical therapy, occupational therapy, and speech therapy for treatment of the enrollees medical condition status post tumor resection.  Findings: The physician reviewer found that this patients records do not demonstrate that continued SNF care including physical therapy, occupational therapy, and speech therapy is medically necessary. There is a lack of evidence that the patient currently requires such SNF services as intravenous or enteral feeding, tracheotomy aspiration, suprapubic catheter care, or treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care or other skilled nursing need. In addition, the documentation does not support that the patient requires skilled therapy services on a daily basis or inpatient services in a SNF. The patient is not expected to make measurable gains within a reasonable and predictable period of time given her therapy notes which reveal inconsistency in progress due to cognitive fluctuations. The patient does not require skilled therapy on a daily basis to prevent deterioration with mobility and/or ADLs. Moreover, the patient does not reveal that she has medical needs that require SNF services to prevent deterioration in her condition or to establish a safe and effective maintenance program as the patient and caregivers were educated in the patients care. Furthermore, the patient does not have continued complex medical conditions that require close involvement from a rehabilitation provider with specialized training and experience in rehabilitation. Therefore, this patient does not require the necessary services on a SNF level of care. Her current needs can be met at a lower level of care such as home with 24-hour support or long-term custodial care.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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar spinal fusion for treatment of her medical condition.  Findings:  The physician reviewer found that the records provided document an incomplete examination with absence of back, hip, vascular and sacroiliac examinations. Thus, all other potential causes of her pain have not been ruled out. The criteria for fusion surgery requires symptomatic spondylolisthesis with functional impairment or progressive neurologic deficit, significant or moderately severe spinal stenosis with instability with functional impairment, which have not been documented. Further, there is no evidence of fracture, tumor or infection. Moreover, the patient has not failed at least six months of conservative management including cognitive behavioral therapy, which is indicated due to her history of depression. All told, the requested lumbar spinal fusion is not medically necessary for treatment of this patients chronic back pain.  Final Result: The reviewer determined that the requested surgery 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 neurological 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

A 52-year-old male enrollee has requested for Nuvigil for treatment of his medical condition. Findings:  The physician reviewer found that Nuvigil and Provigil can be (and have been) used for ADD in adults with good effect and a favorable side-effect profile. Symptomatically, this patients excessive sleepiness and cognitive functioning have improved while taking Nuvigil, and had not improved in response to several stimulants/wakefulness promoting agents for narcolepsy
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ubrelvy (ubrogepant). The records provided for review document that this patient presents with a history of migraines. Treatment has included multiple prophylactic and abortive medications such as nortriptyline, propranolol, sumatriptan, and valproic acid. The patients provider has recommended treatment with Ubrelvy. The U.S. Food and Drug Administration (FDA) has approved Ubrelvy for the treatment of patients with migraine. Studies found Ubrelvy has been shown to be effective and safe in the treatment of patients with migraine. The use of Ubrelvy is indicated for the disease process in this patient, is consistent with accepted standards of medical practice, and is therefore medically necessary. All told, the requested Ubrelvy (ubrogepant) is medically necessary for 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 neurology with subspecialty certification in vascular 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this patients case. Bronchial thermoplasty has been approved by the U.S. Food and Drug Administration. There have been multiple studies citing the benefit of the requested services in this clinical setting. Bronchial thermoplasty may improve asthma control and quality of life. This is a safe treatment for refractory asthma. In sum, the requested bronchial thermoplasty. Final Result: Two of the three physician reviewers found that he 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 physical medicine and rehabilitation 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: Overturned

The parent of a 12-year-old male enrollee has requested 10-12 hours per week of direct applied behavioral analysis (ABA) therapy, 9-10 hours per month of supervision and 5-6 hours per month of board certified behavioral analyst (BCBA) director level management for treatment of the enrollees autism.  Findings:  The physician reviewer found that Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. This patient has a diagnosis of autism through multiple sources and will continue to benefit from ABA therapy. The behavioral concerns that need to be addressed include aggression, maladaptive attention-seeking behaviors, inappropriate vocalizations, eloping behaviors as well as adaptive skills. Therefore, the requested ABA therapy is medically necessary for this patient. The proposed frequency of 10-12 hours per week of direct ABA therapy, 9-10 hours per month of supervision and 5-6 hours per month of BCBA director level management is medically reasonable and appropriate based upon this patients functional deficits.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 49-year-old woman with nearly a two-year history of progressive slowing and rigidity of the right arm. She is seeking a fluro-dopa PET scan for definitive diagnosis of Parkinsons disease. The submitted records indicate the patient has shown a response to Sinemet and a movement disorder specialist has diagnosed probable Parkinsons disease. The Health Plan has denied coverage for the requested PET scan on the basis PET scanning has not been shown to be efficacious for evaluation of the patients condition.PET scanning is an investigational tool in the management of Parkinsons disease. There has been no proven long-term benefit of PET in the treatment of Parkinsonian disorders. While use of PET may confirm a definitive diagnosis of Parkinsons disease, it will not change the patients therapy, which at this time is not disease modifying. Therefore, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 49-year-old woman with an extrapyramidal neurological disorder, possibly Parkinsons disease, which appears to respond to dopaminergic medication. She has been advised to undergo a fluro-dopa PET scan. The Health Plan has denied coverage for the requested PET scan on the basis it is considered investigational for evaluation of the patients medical condition.PET scanning can be very useful in certain clinical settings. However, in cases such as this, clinical observations generally provide the information required to appropriately manage the patients disorder. PET scanning is not likely to have clinical value in this setting. Therefore, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 49-year-old woman who has been diagnosed with probable Parkinsons disease. She has rigidity and has had some response to Sinemet. The patient has requested authorization and coverage for a fluro-dopa PET scan to evaluate dopamine density in basal ganglia. The Health Plan has denied coverage for the requested PET scan on the basis it is considered investigational for evaluation of the patients medical condition.The efficacy of PET scanning in diagnosing Parkinsons disease has not been established. This condition continues to be diagnosed based on clinical factors. PET scanning in this context will not play any role in the ongoing care and management of this patient. The proposed PET scan is academic and is not likely to be superior to standard diagnostic modalities. Accordingly, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A 37-year-old female enrollee has requested emergency services for treatment of the presence of menstrual period over three weeks and cold symptoms.  Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson in the enrollees circumstances would believe she 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.A prudent layperson experiencing vaginal bleeding for three weeks, dizziness for two weeks, and fever with a history of dysfunctional uterine bleeding and uterine fibroids in the past would not believe she was experiencing a medical emergency under these circumstances. While the patient contends that she had been diagnosed with uterine fibroids/leiomyomas and was concerned her symptoms would be life threatening, a prudent layperson in this situation would not consider chronic symptoms of prolonged and heavy vaginal bleeding and dizziness to be a life threatening condition. Although the patient maintains that previous discharge instructions she received from the ED indicated she should seek immediate medical attention in the event of a sudden increase in pain or symptoms associated with her uterine fibroids, the patients symptoms had been occurring for two to three weeks at the time she sought care in the ED. As such, a prudent layperson in these circumstances would have sought care from her primary care provider. Furthermore, the additional symptoms of fever, runny nose and flu symptoms also would not be considered a medical emergency according to a prudent layperson. While the patient indicates she was experiencing a high fever, there is no objective evidence of such at the time she sought emergency services.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested back traction, and a magnetic resonance imaging (MRI) of both knees for treatment of her back and knee pain.  Findings:  The physician reviewer found that the requested services are not supported as medically necessary to treat this patients medical condition. Based on available data, traction therapy for chronic musculoskeletal pain may be effective as part of a totally integrated planned therapy program. This patient does not have a well defined peripheral neuropathy with radiculopathy. The typical indications include internal derangement or meniscal tears of the knees and the clinical records show little indication as to these problems being an important part of her pain experience. In summary, the clinical record does not support the indications for bilateral MRI of the knees and it is not medically necessary to continue to use clinic based traction therapies for management of the patients chronic pain syndrome.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for trametinib dimethyl sulfoxide (Mekinist) tablets. Findings:  The physician reviewer found that Mekinist has been approved for use, either alone, or with Tafinlar, in patients with melanoma that is BRAF mutation positive. There has also been benefit in patients with non-small cell lung cancer and thyroid cancer. However, there is a paucity of data on the use of Mekinist in an adenocarcinoma of the parotid. Overall, the use of mutations to guide therapy remains controversial. In addition, this patients multi-gene assay report that identified the tumor as HRAS positive did not recommend Mekinist therapy. For these reasons, the requested trametinib dimethyl sulfoxide (Mekinist) tablets daily is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.