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

A 54-year-old male enrollee has requested for an MRI for evaluation of her herniated disk. Findings:  The physician reviewer found that based on the clinical information provided, an MRI is not clinically indicated for this patient at this time. An MRI is not necessary to make a change in the patients treatment course at this juncture. The next appropriate step in this case is a consultation with an orthopedist to discuss whether diagnostic studies are needed and, if so, which particular imaging modality would be most useful.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Caprelsa 300 mg tablets. Desmoid tumors are locally aggressive tumors with no known potential for metastasis or dedifferentiation. However, tumor invasion into vital structures and organs can result in substantial morbidity. Given this patients multiple recurrences, further surgical excision would be difficult. Standard treatment options include cytotoxic chemotherapy, pazopanib, or tamoxifen. There is a lack of peer-reviewed medical literature evaluating EGFR targeting medications in desmoid tumors. Therefore, Caprelsa 300 mg tablets 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 subspecialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for an arrhythmia and cardiomyopathy genetic panel. The enrollee was diagnosed with cardiomyopathy at age 15. He experienced cardiac arrest at age 16 and is status post implanted cardiac defibrillator, with moderate mitral valve prolapse. The enrollee has experienced multiple implantable cardioverter-defibrillator shocks, frequent premature ventricular contractions and atrial arrhythmia. The treating provider recommended the arrhythmia and cardiomyopathy genetic panel testing to assess for hereditary cardiomyopathy and/or possible malignant mitral prolapse syndrome. Genetic testing for cardiomyopathy is not considered the standard of care for the management of enrollees with known or suspected cardiomyopathies. There is no evidence of malignant mitral valve prolapse syndrome, which would warrant testing. Genetic testing has not been proven in clinical research trials to provide information which affects outcomes in enrollees with known or suspected cardiomyopathies, and is not recommended by professional societies in this clinical context.Final Result: Two of the three reviewers determined that the requested services were not likely to have been 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for Nutramigen infant formula. The Health Plan has denied this request indicating that the requested formula is not medically necessary for treatment of the enrollee who has a history of severe constipation.Findings: The medical studies show that adverse reaction to cows milk protein is common in infants. The prevalence of cows milk protein allergy (CMPA) ranges from 2% to 7.5%. Immediate symptoms may include vomiting, urticarial, angioedema, wheezing, rhinitis, and dry cough. Later symptoms may include moderate to severe atopic dermatitis, diarrhea, and blood in the stool, gastroesophageal reflux and constipation. A comprehensive history is crucial in making the diagnosis of CMPA, including family history, because the risk is increased in the presence of familial atopic diseases. Because cows milk sensitivity may be associated with sensitivity to soy, soy-based formulas are not recommended. An elimination diet is appropriate to confirm the diagnosis when a patients clinical history is highly suggestive. The literature supports the use of amino acid-derived formulas in severe cases. Hydrolysate formulas such as Nutramigen are medically indicated for infants under one year of age with CMPA. The studies have shown that about half of infants resolve this allergy by the age of twelve months, and the majority within their fifth year. For patients that require formula, Nutramigen Toddler with Enflora LGG is a hypoallergenic formula designed to meet the nutritional needs of older infants and toddlers with CMPA from nine months to 36 months. In this case, the records show this patient has significant developmental delay, refractory constipation with a behavioral component, need for adult dose cathartic medications, and atopic disease (asthma, allergic rhinitis). Accordingly, Nutramigen infant formula is medically necessary for treating this patients medical condition. Final Result: The reviewer determined requested formula 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 pediatrics with sub-specialty certification in pediatric critical care 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:  The enrollee is requesting authorization and coverage for the medication, Orilissa, 150mg tablet. The enrollee has endometriosis, uterine fibroids, and complaints of pelvic pain. She has used acetaminophen 300mg-Codeine 20mg, ibuprofen 600mg, and hydrocodone 5mg/325mg, but they did not help with pain. She reported a 60 percent improvement with vaginal valium. The enrollees physician is requesting renewal of Orilissa, as the enrollee has reported it is the only medication that helps with the pain from her endometriosis. The source of this enrollees pain is not clear from the medical records. The progress notes suggest the pain is due to vaginismus. The enrollee has a very small myoma that should not be causing pain. If the enrollees pain is caused by endometriosis, then the treatment is based on the severity of symptoms. This enrollee did not fail treatment with oral contraceptives or the progestins Danazol or Lupron; nor does she have a contraindication to these products. There are no studies comparing the efficacy, side effects, or long term outcomes between Lupron and Orilissa.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 obstetrics and gynecology and reproductive endocrinology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested acupuncture for treatment of the enrollees abdominal pain. Findings: Two physician reviewers found that this patient has been referred for treatment with acupuncture to possibly help with abnormal gut sensations during feedings. According to the providers notes, this is the presumed reason the patient is uncomfortable during feeding, but this is not an indication for acupuncture. Acupuncture has not been demonstrated to improve patients in this clinical setting. Further, there is a lack of documentation that abnormal gut sensations are the cause of the patients pain. There is no indication in the medical records provided for review that standard testing has been performed to rule out other causes of pain. Thus, the requested acupuncture is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested service 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: All three physician reviewers are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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

A 40-year-old female has requested Lyrica 75mg capsules for treatment of her pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical scenario.  The patient has a mechanical derangement due to meniscal tear, with minimal postoperative physical therapy and minimal attempts at aggressive anti-inflammatory therapy.  Based upon the clinic notes, the patient has not tried moderate analgesics, such as tramadol, NSAIDs or topical agents.  Lyrica treats neuropathically-modulated pain. However, in this patients case, there is a lack of evidence of direct neuropathic pain on examination. All told, there is insufficient evidence supporting the medical necessity of Lyrica 75mg capsules for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for SPECT Scans. He has a history of head/brain trauma with first injury occurring at the age of four or five, when he hit his head on playground equipment. He hit a parked car in an automobile accident and had a bicycle collision while riding downhill. He was air lifted to a trauma center and was unconscious for three days. He requested an evaluation, as he is curious about his brain health. As part of the evaluation, a resting and a concentration brain single photon emission computed tomography (SPECT) study were performed. The most significant findings were the irregularly decreased activity in the anterior poles, moderately decreased activity seen in the temporal lobes bilaterally in both scans, and the milder decreases in the frontal, parietal and occipital lobes; suggestive of a brain injury. Moderately increased activity was noted in the right basal ganglia and in the focal left region of the thalamus at rest. Moderately decreased activity was noted in the inferior orbits of the prefrontal cortices bilaterally. The medical literature notes that SPECT-CT is where two different types of scans are taken and the images or pictures from each are fused or merged together. The fused scan can provide more precise information about how different parts of the body function and can more clearly identify problems, such as tumors or Alzheimers disease. The enrollee underwent the SPECT studies to improve his marital relationship based on improvement of their brains.  However, literature does not support the use of SPECT studies for improvement of the enrollee's brain health. The scientific evidence and peer-reviewed literature does not support a result of improvement in health outcomes to support this service. Literature from a professional society indicates a single-photon emission computed tomography (SPECT) scan is appropriate for individuals with suspected dementia, with localizing epileptic foci preoperatively, for diagnosing encephalitis, for mapping of brain perfusion during interventions, for detecting and evaluating cerebrovascular disease, or for predicting the prognosis of individuals with cerebrovascular accidents.  Other findings with SPECT brain perfusion imaging, for indications such as neuropsychiatric disorders and chronic fatigue syndrome, have not been fully characterized.Final Result: Two of the three reviewers determined that the requested services are 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 psychiatry 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: Experimental/Investigational
Decision: Upheld

The parent of a 17-year-old female enrollee who has suffered from severe back pain for 5-6 years requested authorization and coverage for intradiscal electrothermal therapy (IDET).  The health plan has denied this request indicating that IDET is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.  Because all three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested group speech therapy for treatment of the enrollees autism spectrum disorder.  The physician reviewer found that with the change to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) there is recognition that language delays or language disorders is a separate problem from the autism spectrum disorder. However, with the change to DSM-5 there is also the recognition that pragmatic or group social language deficits are a significant part of the autism spectrum disorder. In this case, the group speech therapy progress reports demonstrate that this patient has made measurable gains from therapy. Moreover, the patients most recent evaluation showed above average pragmatic language skills for age. In this clinical setting, the Health Plans recommendation for continued ABA to address the patients social skills is medically reasonable and appropriate. For the reasons provided, continued group speech therapy is not medically necessary in this clinical setting.  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 pediatrics with sub-specialty certification in developmental and 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 31-year-old female enrollee has requested physical therapy for the treatment of her neck pain. Findings:  The physician reviewer found that the medical records demonstrate that the patient was taught proper body mechanics and a home exercise program during the first five physical therapy visits. However, the progress notes for the patients physical therapy do not show significant progress in terms of pain and function.  Based on this documentation and the patients diagnosis, she would have been expected to perform range of motion and strengthening exercises without supervision in the form of a home exercise program after five skilled physical therapy visits.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested circumcision for treatment of the enrollees redundant prepuce and phimosis. Findings:  The physician reviewer found that circumcision is clinically indicated for patients with phimosis as they are known to be at higher risk for UTIs (Dubrovsky, et al). Currently the medical evidence supports the routine use of circumcision and the American Academy of Pediatrics (AAP) has released a position statement noting that the benefits of circumcision outweigh the risks. Specific benefits identified include prevention of UTIs, penile cancer, and transmission of some sexually transmitted infections, including human immunodeficiency virus (HIV). Even asymptomatic patients may be at risk for cancer and sexually transmitted diseases as de Martino and colleagues reported that in a significant number of boys, subclinical high-risk human papillomavirus (HPV) infections were found in the foreskin. All told, the requested circumcision is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for surgery performed in Syria. This patient was diagnosed with renal cancer by computed tomography scan of the abdomen, which revealed a 2 cm enhancing lesion in upper pole of the left kidney. The patient did not have immediate surgery and went to Syria on vacation. While in Syria her father took her to several physicians and it was determined that surgery was needed for the kidney lesion. She underwent a left partial nephrectomy via 11th rib incision. At issue is whether the surgery performed in Syria was considered emergency medical services as defined in California Health and Safety Code section 1317.1. All medical records provided indicate that this was elective excision of a small (approximately 2 cm) solid left renal lesion. There was no urgent or emergent indication for surgery on this renal lesion, such as bleeding, intractable pain, or paraneoplastic syndrome. It was a small renal cell carcinoma and it most cases surgical removal is recommended to eradicate the tumor, confirm diagnosis, prevent possible future tumor growth or possible spread to other areas of the body. There was no urgent or emergent medical situation in this case that required that the patient undergo left partial nephrectomy overseas on 9/1/18. Final Result: The reviewer determined that the surgery performed in Syria on 9/1/18 was not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in urology 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: Upheld

A 48-year-old male enrollee has requested sub-acute rehabilitation services for treatment of acute coronary syndrome and encephalopathy. Findings:  The physician reviewer found that the submitted clinical information does not demonstrate that additional sub-acute rehabilitation services are medically necessary for this patient. There is inadequate documentation that the patient requires such services. The records provided do not include objective data documenting the patients functional status and current deficits. As such, there is inadequate evidence that the requested services are medically indicated or likely to result in clinical benefit.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested  for the medication Vyvanse (50 mg) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Vyvanse is a long-acting medication and long-acting medications have several advantages in that they prevent dosing multiple times per day; have less potential for addiction and diversion; and their side effects are often lessened due to a more continuous and even dispersion of medication throughout the day. Vyvanse has the added benefit of less potential for diversion, due to the fact that it is a therapeutically inactive molecule until it is hydrolyzed by endogenous enzymes to l-lysine, an amino acid, and d-amphetamine, which is responsible for the therapeutic effect. In other words, it has little known elicit use as a stimulant. This is a significant factor in this case given the patients history of substance abuse.Vyvanse is novel only in its delivery method.  It is converted into its active medication d-amphetamine throughout the day in order to have therapeutic effect. D-amphetamine has been used for many years for the treatment of ADHD. There is no sound evidence to support that Vyvanse should be initiated only after other medications (such as Strattera) have failed. Vyvanse is one of the many FDA-approved medications for treatment of ADHD in children. It has similar side effects to other stimulant medications as well (see Wigal and colleagues). Per the American Academy of Child and Adolescent Psychiatry practice parameters (see Pliszka and colleagues), physicians may use long-acting forms as initial treatment; there is no need to titrate to the appropriate dose on short acting forms and then transfer the patient to a long-acting form. Clinically, long acting medications are almost always preferred, when appropriate. In fact, Vyvanse has been beneficial for this patient, and no significant adverse effects were documented.