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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that there is adequate support in the medical literature to support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. According to the study by Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. As such, 3D breast tomosynthesis 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 diagnostic procedure at issue was 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 diagnostic radiology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 100 hours per month of applied behavioral analysis (ABA) therapy in the school setting for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for 100 hours per month of ABA therapy in the school setting has been established as medically necessary. ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence based interventions available. In this case, the patients parents are requesting continued coverage of ABA therapy in the school setting to address aggression, verbal protests, transitions, compliance, conversation, attending to task, answering wh questions and other issues. A treatment plan has been developed that is consistent with the patients essential health needs and consistent with the diagnosis of autism targeting behaviors and promoting generalization. The recommendation of ABA in the school setting has been recommended to promote the patients independence by addressing his deficits related to his diagnosis of autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

A 56-year-old male enrollee requested increased dosage of Staxyn 10 mg #27 (once a day if needed) for treatment of the enrollees erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication dosage. The need to treat erectile dysfunction is not entirely a medical issue. After serious medical etiologies have been excluded to prevent other medical concerns, the treatment of impotence or erectile dysfunction is based on providing a support to the emotional and psychological well-being and its potential impact on lifestyle and relationships. Although erectile treatment is indicated, the requested dosage is not medically necessary. The alternative of Staxyn 10 mg #6 per month is appropriate. The requested dosage over that amount is not justified by the literature. Therefore, the medical necessity of the requested medication dosage has not been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick for evaluation of the enrollees colon polyps. Findings:  The physician reviewer found that based on the records provided, the patient presents with documented obstructive coronary disease, intolerance to multiple statin medications, and LDL that is significantly above a goal of less than 70 mg/dL while on Zetia medication. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria and statin intolerance is well documented. In this clinical setting, the addition of a PCSK9 inhibitor such as Repatha has been shown to be safe and effective at lowering cholesterol and has been associated with improved cardiovascular outcomes. Therefore, Repatha SureClick 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services provided.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient presented with an intradural extramedullary spinal tumor. However, the need for emergency surgical treatment is not supported by the medical records provided for review. The operative note does not describe an emergency medical condition. There was no risk of immediate paralysis or rapid decompensation.  Accordingly, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for hyperbaric oxygen therapy (HBOT). The patient has reported sudden hearing loss on 1/20/22. The patients provider recommended treatment with HBOT. However, the evidence in the medical literature supporting treatment of sudden hearing loss with HBOT remains limited. Hosokawa and colleagues evaluated the outcomes and prognostic factors in patients who presented with idiopathic sudden sensorineural (SSNHL) hearing loss. The authors reported that in patients who failed to respond to treatment with systemic steroids, HBOT provided small improvements in patients who were unresponsive to initial therapy. Overall, the authors reported a 9.6% chance of definitive improvement with HBOT. Pezzoli and colleagues noted a benefit with HBOT only in patients who started treatment within the first four weeks after onset of symptoms. The records document that this patient was started on HBOT seven weeks after onset of hearing loss. The peer-reviewed medical literature has not demonstrated the efficacy of HBOT more than four weeks after initial onset of symptoms. Given these findings, the 30 treatments of HBOT was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the 30 treatments of HBOT was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not and are 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: Physician reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right cubital tunnel decompression surgery (CPT 64718, 15718, and 64727). This patient presents with complaints of persistent burning right elbow pain with constant numbness and tingling of the right small finger. Clinical examination findings have documented positive Tinels at the cubital tunnel, positive elbow flexion, and subluxation and snapping of the ulnar nerve with neuropathy during flexion. She has failed to improve despite nine months of activity modification, medications, right carpometacarpal (CMC) joint corticosteroid injection, and hand bracing. The patient has signs, symptoms, and clinical findings of cubital tunnel syndrome correlated with an electromyography/nerve conduction velocity (EMG/NCV) study. Current evidence-based medical literature supports proceeding with surgical intervention in this clinical setting. Studies noted that in cases of mild or moderate cubital tunnel syndrome, it is reasonable to attempt activity modification or splinting, as both appear to be equally effective. Researchers reported that conservative treatment might be effective in the early stages of cubital tunnel syndrome. The authors recommend surgery for patients who fail to improve with non-operative treatment, or those with more advanced clinical findings, such as motor weakness, muscle atrophy, or fixed sensory changes. Surgical intervention for primary cubital tunnel syndrome is cubital tunnel decompression surgery. For these reasons, the requested right cubital tunnel decompression surgery (CPT codes 64718, 15718 and 64727) is medically necessary for 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: Upheld

A 37-year-old male enrollee has requested Lovaza for the treatment of his IgA nephropathy. Findings:  The physician reviewer found that the FDA approved indication of Lovaza is for adult patients with very high (greater than 500mg/dL) triglyceride levels. This patient had a normal level of creatinine and a low amount of proteinuria. All told, there is insufficient that Lovaza is medically indicated in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services provided by Hoag Hospital. The records provided for review indicate that the patient no longer met the American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care. The patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive or violent. His short-term memory impairment was not severe enough to require treatment in the residential setting. Although requiring prompting to perform ADLs, he was capable of independently performing them and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the residential level of care. He was medically and psychiatrically stable to the extent that he did not need a 24-hour facility to render the remainder of his care. There were no changes in his medication regimen, and he was not on any anti-craving medications. He was engaged in treatment and was seeking a sponsor. He had demonstrated the capability of prolonged abstinence previously and has had prior exposure to rehabilitation and the 12 step program. He was motivated and was working the program. He was cooperative and participating in his treatment plan. He did require continued treatment for his anxiety and depression, as well as the reported visual hallucinations at night, which could have occurred in the ambulatory setting. Given these findings, the RTC services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue 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 psychiatry with sub-specialty certification in addiction 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ankle surgery for treatment of the enrollee's ankle pain. Findings:  The physician reviewer found that the documentation provided does not support the requested procedure at this time. Ankle arthrodesis is a common treatment used for patients with end stage ankle arthritis. The surgical goal of ankle arthrodesis is to obtain bony union between the tibia and talus with adequate alignment [slight valgus (0-5)], neutral dorsiflexion, and slight external rotation positions) in order to provide a pain free plantigrade foot for weight bearing activities. This patient describes turning in of the foot and that her foot is painful. However, the documentation available does not include a detailed evaluation of the ankle after the surgery to include radiographic evidence of a solid union and description of the position of the foot. The patient has seen five ankle surgeons for a second opinion, all of whom told her to go back to the initial surgeon. Final Result: The reviewer determined that the requested procedure 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 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 patients parent has requested authorization and coverage for Dupixent. Findings: A study found that dupilumab and topical corticosteroids were effective and well tolerated in children aged 6 to 11 with severe atopic dermatitis, significantly improving symptoms and quality of life. Another study report that dupilumab, approved for the treatment of atopic dermatitis, has been well studied in patients aged six and older, with expanded indication down to six years of age. In this case, the patient has severe atopic dermatitis and has tried and failed topical therapies, including steroidal and nonsteroidal therapies, of varying strengths and systemic agents, such as prednisone and Xolair. Given that current medical literature reports that Dupixent is safe, well tolerated and effective in treating children with atopic dermatitis, the requested medication is medically indicated. Therefore, Dupixent 300 mg/2 mL 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 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: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested for Kapidex for treatment of his dyspepsia. Findings:  The physician reviewer found that the patient try the preferred PPIs as both a single and double dose is medically appropriate.  At this time, the medical necessity of Kapidex for the treatment of this patients symptoms has not been established
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested for an X-Stop procedure for treatment of his degenerative disc disease. Findings:  Two physician reviewers found that there is not enough long-term outcome data to establish the safety and efficacy of the X-Stop procedure. There is some concern about this device over time and more outcome data is needed about this procedure before it can be recommended. Standard lumbar decompression and fusion is the standard of care for treatment of this patients condition and was more appropriate for this patient than the X-Stop procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested authorization and coverage for a lumbar facet rhizotomy for treatment of the enrollees chronic low back pain. Findings:  Two physician reviewers found that the patient presents with chronic axial low back pain that is believed to be caused by facet arthropathy at L4-5 and L5-S1, as well as a possible sacroiliac joint trigger. The patient is status post anterior fusion at the L4-5 and L5-S1 levels with good anterior fusion mass, but no/limited fusion of the facet joints or posterior elements. The patient has consulted a surgeon, who has stated there is no current indication for further surgery at this time and the other lumbar levels appear to be free of neurocompressive lesions. The patients history demonstrates a good response to facet rhizotomy a couple years ago and more recently, temporary but good relief to diagnostic facet injections. The patients provider has recommended a repeat rhizotomy of the L4 medial branch, L5 dorsal ramus and S1 lateral branch, as a treatment option to control the patients facet pain and decrease her medication usage. The Health Plan has denied the requested lumbar facet rhizotomy, due to the presence of previous fusion at the suggested levels of the rhizotomy.The patient has continued lumbar pain in the axial region after anterior interbody fusion, with suspected facet pain. Per the Health Plan guidelines, facet rhizotomy is not recommended at a surgically intervened level. However, those recommendations apply to posterior fusion where the facet joints are fused and the anatomy around the medial branch nerves is destroyed. In this case, the patients facet joints are still mobile, as there was no 360 degree fusion and they are still a potential source of pain and disability. The patient has responded well to facet blockade and previous rhizotomy and still has axial pain in an L4-5 and L5-S1 facet joint pattern. The fact that there is notable arthropathy at the facets and there is no posterior fusion noted on CT scan, allows for the possibility of continued facet dysfunction and the diagnostic blocks are indicate of active facet pain. As such, lumbar facet rhizotomy is an acceptable option in this patients case.  The patient has axial pain greater than six months in duration, is responsive to facet blockade and the anatomy of the medial branches is intact. Therefore, rhizotomy is feasible in this case and given the workup and positive response to facet blocks and previous rhizotomy, the procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.