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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for a catheter ablation procedure to correct her symptomatic, paroxysmal atrial fibrillation. Data from Holter monitoring showed premature atrial contractions (PACs). Multiple options were discussed and the enrollee selected Eliquis and flecainide.  At a subsequent visit, notes indicate she had started Eliquis but the decision was made to perform catheter ablation rather than a class I or III antiarrhythmic medication. Atrial fibrillation ablation (pulmonary vein isolation), mapping atrium of ventricle, intracardiac echocardiography, and ultrasound guided vascular access were performed due to having highly symptomatic paroxysmal atrial fibrillation refractory to medical therapy.  According to the medical literature, there is limited evidence that catheter ablation is more effective than medical management with class I or III antiarrhythmic agents.  Recent guidelines and expert consensus statements rate catheter ablation for symptomatic paroxysmal atrial fibrillation a class II, (reasonable) recommendation for enrollees prior to class I or III arrhythmic medications. This enrollees clinical characteristics did not put her at increased risk from these medications and there is insufficient evidence in the record of a medication trial prior to the catheter ablation.  As to date, literature does not support catheter ablation as first-line therapy for paroxysmal atrial fibrillation. Rather, literature supports a trial on an antiarrhythmic medication (i.e. Flecainide), and consider catheter ablation if the enrollee continues to have break-through atrial fibrillation on the antiarrhythmic medication.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiovascular Disease 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: Upheld

The patient is a 44-year-old female who has regained weight after gastric bypass surgery in June 2001. The patient indicates her weight regain started as the result of the stress of family problems. The patient wishes to undergo repeat gastric bypass surgery and therefore, has requested authorization for a gastric bypass surgery consultation. The Health Plan had denied the patients request on the basis that gastric bypass surgery is not medically indicated. The Health Plans denial should be upheld. Given the patients history of weight regain following her initial weight loss surgery, it is expected that the patient will continue maladaptive eating behavior with a repeat procedure. There is no evidence of a specific problem relating to the prior procedure. The only indication for a revision procedure would be the presence of a gastrogastric fistula. It is likely that the patient will receive greater benefit from dietary counseling and treatment for stress and anxiety than from repeat weight loss surgery. Therefore, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested authorization and coverage for Acthar, 80 mg subcutaneously, twice per week for treatment of the enrollees renal insufficiency status post right nephrectomy.  Findings:  The physician reviewer found that the cause of this patients nephrotic syndrome is not known with certainty because the patient has not had a kidney biopsy. However, it seems likely that this patient has FSGS secondary to hyperfiltration with a solitary kidney, in the setting of hypertension, despite being well controlled. This is a relatively common occurrence in patients with underlying renal risk factors, specifically hypertension, in patients who have a solitary kidney. Typically these patients do not respond to any immunosuppressive medications as it is not an immune-mediated process. It is also unlikely that he has primary immune-mediated FSGS that would potentially be steroid responsive. This patient could have developed idiopathic membranous nephropathy in his remaining kidney, which is one of the most common nephropathies in his age group. The other possibilities would include IgA nephropathy given his ethnic background and amyloidosis or other GN. Typically idiopathic membranous nephropathy would be treated with Cytoxan/prednisone or cyclosporine/prednisone or monotherapy tacrolimus as first-line treatments. The use of cyclosporine or tacrolimus with advanced renal failure in an elderly patient with likely underlying nephrosclerosis could potentially worsen renal function secondary to arterial vasoconstriction. The Cytoxan/prednisone combination (referred to as a modified Ponticelli protocol) would also likely be contraindicated in this particular situation due to the difficulty in dosing Cytoxan in advanced renal disease, the low possibility of benefit, and side effects from the Cytoxan. The most recent data suggests in 10 patients who had idiopathic GN, there was a 90% response rate to ACTH. Ponticelli and colleagues showed similar results between the ACTH group and the patients who received the Ponticelli protocol. The clinical justification to use Acthar in this particular situation is for idiopathic membranous nephropathy, which cannot be excluded secondary to lack of biopsy. In this patients case, the use of Acthar in idiopathic glomerulonephropathy (GN) is further supported by the high risks associated with the standard medications as noted in the medical literature (Bomback, et al). The patients provider has indicated that Acthar may help the patient. As the studies suggest similar health outcomes in terms of reduced proteinuria with ACTH or methylprednisolone and cytotoxic agents, the requested medication has been shown to be medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested resumption of acute rehabilitation following cranioplasty and subsequent seizure for medical treatment of his traumatic brain injury.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate that the patient had severe traumatic brain injury requiring medical and rehabilitation services.  He had stabilized prior to cranioplasty, with appropriate discharge plans.  Following cranioplasty, there was temporary setback attributed to a seizure.  Seizures do not cause long-lasting deficits, but can exacerbate pre-existing neurologic deficits.  The records do not indicate that there is ongoing impairment that would require inpatient rehabilitation services.  The medical records support home or skilled nursing facility care with ongoing therapy in a brain injury day treatment program in this clinical setting.  All told, the requested resumption of acute rehabilitation is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of benign growths on left cheek and under left breast. This patients records document the presence of a left lower cheek lesion that has increased in size over the past year and a lesion under the left breast. As noted in the medical literature, the removal of benign seborrheic keratoses is not supported as medically necessary for treatment of this patient. The growths are not blocking an orifice, causing pain, or infection. The photographs and records support that these are normal tumors that are benign. Therefore, the requested removal of benign growths on left cheek and under left breast is not medically necessary for treatment of this patient. 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. Benign growths are developmental abnormalities. Based on the available documentation, the requested removal of the benign growths is not being requested to improve function or address infection. Moreover, the requested benign tumor removal will not create a more than minimal improvement in the patients appearance. Given these findings, the requested removal of benign growths on left cheek and under left breast is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for advanced lipoprotein testing (CPT 83704). Findings:  The physician reviewers found that there is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated use of advanced lipoprotein testing for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology (ACC) do not support the use of advanced lipoprotein testing. According to the ACC, there is a lack of data to indicate a benefit for advanced lipoprotein testing over the basic lipid profile. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. Therefore, the advanced lipoprotein testing (CPT 83704) performed was not likely to have been more beneficial than the standard testing options for the evaluation of this patient. Final Result: 2 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-specialty 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 act internal medicine with sub-specialty certification in cardiovascular disease actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested wireless capsule endoscopy for an evaluation of her medical condition. Findings:  The physician reviewer found that the proposal is for a wireless capsule endoscopy to visualize the remainder of small bowel. An upper gastrointestinal study (UGI) with a small-bowel follow through (SBFT) was negative. It is of the utmost importance in this case to determine whether the small bowel is significantly involved with Crohns disease. This will impact whether the patient should be placed on 6-mercaptopurine (6-MP) and long-term steroid treatment. Since the proposed procedure is likely to affect treatment decisions made in this case, it is medically reasonable and appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old female with a body mass index (BMI) of 41. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. She wishes to undergo gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 41, gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested a third series of Synvisc injection for treatment of her knee osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to Goldberg and Goldberg, Although several randomized controlled trials have established the efficacy of this treatment modality, additional high quality randomized control studies with appropriate comparison are still required to clearly define the role of intra-articular HA [hyaluronan] injections in the treatment of osteoarthritis. While there have been some studies suggesting Synvisc injections may be efficacious for the treatment of osteoarthritis, there is a lack of data demonstrating that the continued use of Synvisc injections is effective. All told, the requested Synvisc injections are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested  residential treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient required ongoing placement in a structured residential treatment environment during the period at issue.  Given the intensity of the patients prior behaviors, her struggle with genuine insight into her emotional issues, and her fragile sense-of-self, she required the therapeutic approaches associated with a residential treatment level of care. This level of care was appropriate and necessary to develop distress tolerance skills, affect regulation, and more adaptive impulse control. As such, residential treatment level of care during the time period at issue was medically necessary and should be covered by the Health Plan.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for vaginal Botox injections into the pelvic floor muscles for treatment of the enrollees pelvic pain.Findings: All three physician reviewers found that treatment of chronic pelvic pain often includes the use of narcotics, which have many negative properties and side effects. However, the medical studies have indicated that treatment of chronic pelvic pain with Botox is a relatively straight forward treatment with fewer serious side effects. The proposed mechanism of action blocks prolonged muscle contraction, spasm, and inappropriately high muscle tone.  There have been a number studies that support the use of Botox for the treatment of chronic pelvic pain.  Based on the literature, it is likely that this patient will experience improvement in her symptoms with this treatment regimen. The record noted that this patient has not found relief with traditional pharmacological and non-pharmacological therapies. All told, vaginal Botox injections into the pelvic floor muscles were and are likely to be more effective than the standard modalities for treatment of this patients medical condition. Final Result: The  three reviewers determined that the services at issue were and 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: All three physician reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested for NESS L300 Foot Drop System for treatment of his foot drop secondary to cerebrovascular accident.  Findings:  Three physician reviewers found that the BioNess L300 is an FES that received FDA clearance to provide ankle dorsiflexion in patients with drop foot following an upper motor neuron injury or disease. Specifically, the system is intended to provide ankle dorsiflexion in patients with foot drop following an upper motor neuron injury or disease. During the swing phase of gait, the BioNess L300 electrically stimulates muscles in the affected leg to provide dorsiflexion of the foot. All told, the requested BioNess L300 FES is likely to be more beneficial than available standard therapies for treatment of this patients foot drop.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Botox injections for treatment of the enrollees intractable chronic migraine without aura. Findings:  Two physician reviewers found that Botox has been established as safe and effective for chronic migraine, and is U.S. Food and Drug Administration (FDA) approved for this condition. No other preventives are FDA approved for treatment of chronic migraine. While there is evidence of benefit with topiramate, direct comparison favors Botox, in terms of treatment adherence, side effects, and overall benefit. Per research, Botox and topiramate demonstrated similar efficacy in the prophylactic treatment of chronic migraine while patients treated with Botox had fewer adverse events. Final Result: The reviewers determined that the service at issue was 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: Reviewer 1 is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. Reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in neurology 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

A 59-year-old female enrollee has requested  for deep brain stimulation surgery for treatment of her Parkinsons disease. Findings:  The physician reviewer found that this patient clearly has Parkinsons disease and demonstrates the cardinal symptoms of bradykinesia, rigidity, rest tremor and postural instability. With regard to rigidity, there is a known On-Off phenomenon that commonly occurs, and patients will not demonstrate rigidity when they are On.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ketamine therapy. Findings: Ketamine is reserved as an option for management of patients with treatment refractory depression, which is defined by failure of adequate improvement in depressive symptoms after two antidepressants trialed for appropriate durations and at appropriate dosages. Based on the documentation provided for review, this patient has not undergone the requisite two medication trials. Additionally, with reduction of his substance use, adjustment of lithium, and initiation of regular individual psychotherapy, the patient has shown positive response to treatment over the course of the last couple of months. The patient has reported subjective symptomatic improvement and his Personal Health Questionnaire scores have decreased to half of his score from October 2021. Given these findings, the patient does not meet the criteria for a diagnosis of treatment refractory, severe depression with an indication for ketamine therapy. Therefore, the requested ketamine therapy is not medically necessary for the 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for sclerotherapy. Findings:  The physician reviewer found that indications for intervention in varicose veins are based on the persistence of symptoms after a trial of conservative therapy including compression stockings, diet, exercise, elevation and use of nonsteroidal anti-inflammatory drugs. This is not documented in this patients case.  The records do not document that the patient has failed a trial of compression stockings.  Based on the duplex, there is no indication for primary treatment of varicose veins.  Final Result: The reviewers determined that the requested services 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: the physician reviewers are board certified in vascular surgery 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.