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

A 53-year-old male enrollee has requested inpatient psychiatric hospitalization level of care for treatment of his major depressive disorder, recurrent, severe, opioid dependence on agonist therapy, rule out conversion disorder, and rule out depression secondary to general medical condition.  Findings:  The physician reviewer found that in this patients case, the medical records fail to justify the continued need for inpatient psychiatric hospitalization after the date in question.  Despite having not achieved cognitive baseline functionality, the patient had improved and evidenced no mental health issues that required treatment in 24-hour supervised setting.  He was not a danger to himself or others.  He was not gravely disabled due to a psychiatric syndrome and had no acute medical issues.  Per nursing, he demonstrated orientation and the ability to maintain self-care.  Continuing care from a multi-disciplinary treatment team was indicated.  However, such care could be facilitated in the community.  All told, inpatient psychiatric hospitalization treatment level of care during the said timeframe was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Dupixent injections. Atopic dermatitis is an inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function, reflecting underlying alterations in keratinocyte differentiation. The disease may be associated with significant morbidity, particularly when complicated by secondary infection. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. Treatment of atopic dermatitis usually starts with topical agents, such as corticosteroids, as well as phototherapy. Skin inflammation in atopic dermatitis results from inherited and acquired insults to the skin barrier, and agents that normalize the skin barrier reduce the dependence on topical steroids. Tacrolimus ointment and pimecrolimus cream have been demonstrated to be safe and effective in the treatment of patients with atopic dermatitis. Dupixent has been demonstrated to significantly reduce the clinical manifestations of moderate to severe atopic dermatitis. It also significantly reduces the pruritus of moderate to severe atopic dermatitis, thus improving quality of life. Dupixent had been approved for the treatment of moderate to severe atopic dermatitis. The Health Plans requirement for trial and failure of systemic immunosuppressors should be waived for this patient due to her comorbidity of severe asthma. Therefore, Dupixent injections are 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 dermatology 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 40-year-old female enrollee has requested a PET scan for evaluation of her adenoid cystic carcinoma.  Findings:  Three physician reviewers found that the patients disease status has been monitored with serial PET scans.  Adenoid cystic carcinoma (ACC) of the trachea is a rare tumor.  This patient has had surgical resection of the tumor followed by radiation.  Standard imaging with MRI has shown some soft tissue within the posterior trachea felt to be post-surgical change.  The prior chest MRI also showed a mildly increased subcarinal lymph node which did not have increased uptake on the corresponding PET study.  Recurrence of ACC is usually found locally, although there are reports of distant metastatic disease.   As ACC is a rare tumor, the PET studies on patients with known ACC are limited.  Of the studies published in the peer-reviewed literature in regards to ACC, PET studies have been shown to be clinically useful for staging purposes and for evaluation for distant metastases in patients with known ACC.  As this patient has had multiple tracheal surgeries, PET scan can assist in the differentiation of scar tissue versus recurrent tumor.  Thus, the PET scan was likely to have been superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for panniculectomy and abdominoplasty. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. This patients panniculus hangs well below the level of the pubis to at least the mid-thigh. The pannus is thick and heavy, and the patient complains of difficulty ambulating. She has a chronic rash, but this has not been documented to be disabling. The patient has an intertrigal dermatitis underneath her abdominal pannus, but there is no report of failure of appropriate medical treatment of the rash. The provider recommended surgical intervention to alleviate the inability to walk normally. Based on the evidence-based literature, the requested panniculectomy is medically necessary. However, the requested abdominoplasty is not medically necessary for treatment of this patient. The records provided for review demonstrate that a panniculectomy will be adequate to address the patients condition and the additional abdominoplasty is not medically necessary. 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. Applied to this patient, the requested abdominoplasty is not reconstructive in nature. A lax abdomen with an abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The patients pannus is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. Further, an abdominoplasty would not improve the patients function or provide a more than minimal improvement in the patients appearance. All told, the requested panniculectomy is medically necessary, while the requested abdominoplasty is not medically necessary or reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested Imitrex nasal spray and injections for the treatment of her migraine headaches. Findings:  The physician reviewer found that the patient uses Imitrex SQ about twice per month for severe migraines upon awakening.  She also uses Imitrex nasal spray for less severe headaches. This is medically appropriate and not excessive for Imitrex usage.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a motorized scooter (K0800 power operated vehicle, group 1 standard).Ornitz and Legeai-Mallet state that hypochondroplasia is caused by mutations in the gene encoding fibroblast growth factor receptor 3 (FGFR3). The clinical manifestations of these disorders include short stature, head/facial deformities, accentuated lumbar lordosis, limb shortening, hand deformities, and genu varum. The stature loss is primarily caused by limb shortening, with disproportionate involvement of the proximal limb segment, a pattern that is called rhizomelic limb shortening. Clinical manifestations may not be evident in early childhood. Potential treatment approaches for hypochondroplasia include use of recombinant human growth hormone therapy and surgical interventions for limb lengthening. In this case, the patient has hypochondroplasia, with short stature and short limbs. He has no focal neurological deficits and is ambulatory in the home without an assistive device. He was able to ambulate in the clinic independently, with good balance and without an assistive device when he was evaluated by physical therapy. A power mobility device has been proposed because it is reported that he cannot self-propel a manual wheelchair for long distances. However, a power mobility device for longer distance recreational travel is not a medical necessity. Therefore, a motorized scooter (K0800 power operated vehicle, group 1 standard) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment  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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRT) to the right breast. Findings:  The physician reviewer found that IMRT may be indicated in the treatment of breast cancer when conventional techniques are not adequate to meet dose volume constraints for critical normal structures (Hahn, et al.; Jackson, et al.). On review of this patients medical records, there is indication that standard dose metrics cannot be met with standard dose planning techniques using three-dimensional (3D) conformal treatment planning methods. A plan comparison demonstrated that the right lung was 30% with IMRT and 55% with standard 3D planning. The high lung dose with the standard 3D planning is well above the standard lung metric and would be associated with a high risk of lung toxicities. The reason the standard lung metric cannot be met with this patient is due to her large breast volume that requires treatment. Considering the patients unusual chest wall anatomy and support for IMRT to significantly reduce the volume of lung receiving radiation therapy, the requested IMRT to the right breast is medically necessary for 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 radiation oncology 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 patient is a 63-year-old male on treatment with Hytrin for prostatism and Viagra for erectile dysfunction. A year ago the patient reportedly had a PSA of approximately four and has experienced increased levels of 9.2 on 5/5/04 and 9.3 on 5/28/04. On 7/16/04, the patient underwent a twelve core ultrasound-guided prostate biopsy, at which time digital rectal examination revealed some firmness on the right. One of the six biopsy cores on the right revealed prostate adenocarcinoma, Gleason grade six (3+3). Three of the six cores on the left revealed prostate adenocarcinoma, Gleason grade six (3+3) at two sites and Gleason grade seven (4+3) at one site.Partins Table probabilities depend on clinical staging, but whether considered T1c, T2a or T2b, the chance of this cancer being found to be organ confined to the prostate at the time of surgery is under 50%. Potentially curative procedures include surgery, specifically radical retropubic prostatectomy with pelvic lymphadenectomy, open or laparoscopic, and radiation therapy, brachytherapy or external beam. The patient wishes to undergo laparoscopic radical prostatectomy. The Health Plan has determined a laparoscopic radical prostatectomy is not medically necessary for treatment of the patients prostate cancer.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an eight-year-old male with a diagnosis of cerebral palsy with spastic diplegia associated with periventricular leukomalacia are requesting for authorization of continued intensive physical therapy.  Reviewers Findings:The reviewing physician found that there is no evidence that these therapies provide long-term benefit above and beyond standard therapy and home programs.  The physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

SummaryThe patient is a 56 year old male with lymphocytic leukemia (CLL) which was refractory to alkylators, Fludara and Rituxan.  He is asking for reimbursement for two cycles of the OFAR chemotherapy.  The Health Plan denied his request, indicating the oxaliplatin included in this chemotherapy regimen was not medically necessary.The reviewer concluded that that the chemotherapy was medically necessary and that the Health Plan denial should be overturned.Analysis and FindingsClinical Facts:  The patient has CLL which was refractory to alkylators, Fludara and Rituxan.  He was treated with a regimen of oxaliplatin, fludarabine, cytarabine and rituximab (OFAR). The patient had an excellent response, optimizing his candidacy for allogenic transplant.Reviewers Findings:The reviewer indicated that the literature submitted by the patients providers is sufficient evidence of the potential benefit of the OFAR chemotherapy regimen in the treatment of refractory CLL. The reviewer also stated that the patient will clearly benefited from the protocol which included the disputed oxaliplatin chemotherapy.  This reviewer concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested Lyrica 75mg for the treatment of her left gluteal bursa pain. Findings:  The physician reviewer found that Lyrica is often used off-label for a variety of conditions, including radiculopathy or radiculitis. Lyrica has been shown to decrease neuronal hypersensitivity by binding to the alpha 2 delta subunit of the voltage-gated calcium channel, thus decreasing excitatory neurotransmitter release among neurons. Gabapentin is a medication similar to Lyrica in that it has an analogous mechanism of action and is used in many of the same conditions. Many patients report comparable benefit with Gabapentin. However, some patients note better outcomes on Lyrica versus Gabapentin, perhaps related to better compliance on twice daily dosing of Lyrica versus three times daily dosing of Gabapentin. Lyrica has a linear pharmacokinetic profile in that there is a direct linear relationship between higher doses and clinical effect. Gabapentin has a plateau effect, as higher doses may not have a directly linear increase in therapeutic effect. This patient is noting benefit with Lyrica without limiting side effects. It is rather possible that the patient would have similar efficacy from Gabapentin. It is medically appropriate for the patient to have a trial of Gabapentin, and is it medically appropriate for the Health Plan to provide coverage for Lyrica only if there is an inferior response or adverse side effect.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old female enrollee has requested the Vest Airway Clearance System (Vest) for the treatment of her bronchiectasis. Findings:  Two physician reviewers found that the patient has been treated appropriately with ABX-mucous retrieval without success. She has utilized the Vest since March 2007 with significant benefit. The Vest has adequate data to support it as an effective tool in the treatment of cystic fibrosis and bronchiectasis of other etiologies. This patient has made adequate attempts at clearance utilizing other available therapies (e.g., chest physiotherapy, flutter device) without sustained benefit. Therefore, the records demonstrate that the Vest is the most beneficial treatment for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a male who has requested reimbursement for skilled nursing facility (SNF) level of care services. The Health Plan has denied this request, indicating that the services at issue were not medically necessary for treatment of the patients medical condition. In June 2018, the patient was transferred from a long-term acute care facility to an SNF. As of July 2018, the patient had plateaued with respect to his functionality. There were no ongoing skilled rehabilitation; no nursing or medical needs that required care at the skilled nursing facility level. In this case, the patient has severe heart failure with an ejection fraction of 15 percent. He had poor exercise tolerance. End-stage chronic heart failure with a reduced ejection fraction is a condition with very poor outcomes in general. The best and only true cure for this condition is cardiac transplantation. The patient was at a long-term acute care hospital from September 2017 to June 2018, receiving therapies. In mid-June 2018, he was transferred to an SNF, where he made minimal to no progress with therapy services, compared to his functional status in May 2018 at the long-term acute care facility. The patients progress was limited to the degree that the heart transplant clinic had recommended a neurological evaluation for further evaluation of his deconditioned state. There is no documentation of this evaluation, or indication that there is a treatable or reversible condition of his leg weakness or generalized weakness, neurological in nature or otherwise. As of July 2018, the patient had plateaued with respect to his functionality. There were no ongoing skilled rehabilitation, nursing or medical needs documented to demonstrate the patient required further care at the skilled nursing facility level. He could have returned to the community with his social supports, custodial level assistance and outpatient therapy services for basic restorative strengthening and endurance exercises, as well as for cardiac rehabilitation. Therefore, the SNF level of care services were not medically necessary.Final Result: The reviewer determined that the requested services were 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:  The enrollee is requesting authorization and coverage for right knee replacement surgery. The enrollee has advanced arthritis of the right knee.  The enrollee has a body mass index of 39.31.  Options were discussed with the enrollee during a follow-up visit with her orthopedist; including weight loss.  The enrollee understands the increased risk of illness and even death due to her high body mass index and wishes to proceed with a right total knee arthroplasty. The enrollee reports she needs the surgery as soon as possible.  She cannot stand without a walker and can only walk a short distance with her walker before her knees buckle and give out. Research shows people with a high body mass index are at higher risk for infection and dislocation after knee surgery. Research shows people with a high body mass index who have knee surgery are also at risk for longer operating times, longer hospital stays, and higher rates of implant failure than people with a lower body mass index. Studies show people with a body mass index greater than 30 experienced more complications compared to people with a lower body mass index, and these complications increased as the body mass index increased.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Kalydeco (ivacaftor) for medical treatment of her cystic fibrosis.  Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient has cystic fibrosis transmembrane conductor mutation R117C.  The U.S. Food and Drug Administration (FDA) approved the use of Kalydeco for treatment of patients with cystic fibrosis who have mutation R117C. Thus, the requested medication, Kalydeco, is FDA-approved for the patients medical condition and is medically necessary. All told, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee requested rhizotomy for medical treatment of his sacroiliac (SI) joint arthropathy and lumbago.  Findings:  Three physician reviewers found that SI rhizotomy (neurotomy) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The review by Muhlner indicates that there is limited evidence in treating SI joint syndrome with radiofrequency neurotomy. Based on the limited evidence supporting radiofrequency neurotomy in SI joint syndrome, rhizotomy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested Byetta 5mcg/0.02ml injectable for the treatment of her diabetes. Findings:  The physician reviewer found that the patients hemoglobin A1c is at a level considered to be the upper end of adequate control by the American Association of Clinical Endocrinologists and good control by the American Diabetes Association. Actos has in fact been shown to probably decrease heart disease. Although Actos may have contributed to weight gain initially, data suggests that by one year of treatment, weight is back at baseline. The requested medication is not medically indicated for this patient.