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

The patient is a 53-year-old man with a 20-year history of a trigeminal autonomic cephalgia most consistent with chronic cluster headache. The patient has nearly daily severe, incapacitating headaches with associated autonomic features that respond to Imitrex injections and partially to oral triptans. The patients neurologists have suggested reducing his use of triptans. He has tried and failed Topamax, Depakote, Neurontin, Verapamil, Lithium ES, Indocin, Lyrica, and Cymbalta. The submitted records do not include information about the dosing or duration of these medications.The patient is seeking coverage for reimbursement for his prior use of Imitrex as well as authorization for continued use of Imitrex at a frequency of two injections or two tablets per day. The Health Plan has denied this request on the basis that the quantity of medication at issue was/is not medically necessary.The patients headache disorder is most suggestive of chronic cluster headache. The chronic use of daily triptans such as Imitrex may lead to an element of medication overuse headache, and the patients neurologists have suggested reducing the frequency of the patients triptan use. It appears the patients primary care physician has been providing the patient with triptans.The submitted records document that the patient has been receiving Toprol and Crestor, which seems to indicate that he has hypertension and hyperlipidemia. In addition, it appears the patient is a smoker. In light of these potential cardiac risk factors, the use of Imitrex may be contraindicated and it appears a cardiac evaluation would be appropriate. Additionally, given the patients severe and complicated headache disorder he may benefit from a referral to a headache specialist center. In any event, daily use of Imitrex (injectables or tablets) is not medically appropriate or clinically indicated.For the reasons set forth above, I have determined the quantity of medication at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male enrollee has requested for occupational therapy (OT), speech therapy (ST) and physical therapy (PT) for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and executive dysfunction. Findings:  The physician reviewer found that there are no medical indications for OT, PT or ST. The Fast ForWord Program is an educational program (software) that helps with processing for improving reading, understanding, etc., and may be beneficial for the patient. This program is usually provided in the school setting and does not require administration by a speech therapist.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for implantation of motor cortex stimulator in the brainFindings: Three out of three physician reviewers found that the authorization and coverage for implantation of motor cortex stimulator in the brain is likely to be more beneficial for the enrollee than any available standard therapy.Neuropathic facial pain syndromes are known complications of dental procedures. Although this pain is generally unilateral and in the region of the face and mouth/jaw, it often involves continuous burning pain symptoms. It is well-established that the continuous feature of a chronic pain syndrome is a poor prognostic feature. In the context of an overall poor response to all treatments, conservative treatment with medications is recommended as the first approach. MCS is a technique that has been evaluated for the treatment of chronic pain syndromes. Atypical facial pain is one indication. A small retrospective case study by researchers explored this strategy for patients with chronic pain syndromes, four of whom had chronic atypical facial pain syndromes. Overall, for all patients with chronic pain syndromes, these investigators reported 19 out of 20 patients experienced a positive response, including those with atypical facial pain. A study suggested similar positive results for neuropathic pain syndromes, including atypical facial pain. Further, researchers conclude that MCS may be useful for patients with chronic neuropathic orofacial pain syndromes who do not respond to other treatments.In this case, the patient has facial pain that has been refractory to many of the routine treatment strategies for facial pain syndromes. The patient has tried myriad medications of multiple classes, most of which have yielded no relief. The patient is taking four medications at present, including potent oral narcotics, that provide only minimal relief. Tricyclic antidepressants and anticonvulsants have proven ineffective for this patient. The literature suggests that MCS can be beneficial for this patient. Therefore, implantation of motor cortex stimulator in the brain is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in neurological 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines noted that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. Based on the submitted records, this applies to this patient. Patients require safe and stable living environments in order to develop recovery skills. In this patients case, residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Thus, residential treatment center services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for physical therapy. Physical therapy is appropriate to treat individuals with poor health or injury so that they can return to past level of functioning with the hope that they will show significant improvement in a short period of time. In this case, the submitted records document that the patient has completed 22 physical therapy sessions for back and foot pain. The patient has been taught a home exercise program to continue on his own. The records reviewed do not support the patients compliance with the home physical therapy or with continued use of orthotics which were recommended for treatment of his plantar fasciitis. As such, the medical necessity of the requested physical therapy has not been established. 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 podiatry 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

The patient is a 50-year-old male with daytime somnolence confirmed by MSLT with mean time to sleep 6.5 minutes. His condition has been attributed to idiopathic hypersomnolence though there are references to obstructive sleep apnea with a failed CPAP trial. The patient has had an affirmative clinical trial with Provigil with decreased sleepiness and fatigue. Finally, the patient remains symptomatic without Provigil therapy.  The Health Plan has denied authorization and coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.Though there is neither polysomnography confirmation of obstructive sleep apnea nor confirmation of narcolepsy, there is significant peer-reviewed medical literature to show Provigil's effectiveness in the treatment of daytime somnolence. The submitted clinical documentation demonstrates the patient has excessive daytime sleepiness, which is adversely affecting the patients work performance. Clinically, there is an inference of risk of falling asleep while driving. Provigil has been an effective therapy for the patient. Given the patients therapeutic response, continued treatment with Provigil is medically appropriate and indicated. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 5000 units of rimabotulinumtoxinB every three months by injection. There is a lack of peer-reviewed publications regarding the use of rimabotulinumtoxinB for treatment of dysphagia associated with ALS. There is data supporting the effectiveness of botulinum toxin type A as effective for dysphagia related to ALS. The records do not indicate a rationale for using type b toxin or indicate a contraindication to type A toxin. Moreover, the literature does not support the requested regimen of 5000 units of rimabotulinumtoxinB in lieu of the 2500 units approved by the Health Plan. All told, the requested 5000 units of rimabotulinumtoxinB every three months by injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested 5000 units of rimabotulinumtoxinB every three months by injection 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 requested 5000 units of rimabotulinumtoxinB every three months by injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified 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: Upheld

The patient is a 39-year-old woman weighing 125 pounds with large breasts. The submitted information indicates the patient has strap grooving secondary to macromastia. It has been recommended the patient undergo breast reduction surgery. The Health Plan indicates the patient does not meet criteria for authorization of breast reduction surgery. The submitted information does not demonstrate that the requested procedure is medically indicated. Based on the information provided, the extent of the patients pendulous breasts does not seem excessive. Although the patients symptoms may be associated with macromastia, there is not sufficient documentation to demonstrate that the requested procedure is medically justified. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested gynecomastia surgery for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that gynecomastia is considered a normal variation of puberty and typically spontaneously regresses within 18 to 24 months. If adolescents have surgical therapy before or near completion of their puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence.  The use of mastectomy for gynecomastia in patients under the age of 18 or in those who are not yet at least 18 months after the end of puberty, as in this patients case, is not considered an acceptable alternative to nonsurgical forms of treatment.  In this patients case, the surgery at issue was not medically indicated. Additionally, the patients condition did not constitute an abnormal structure of the body and may have resolved at the conclusion of puberty. All told, gynecomastia surgery was not reconstructive in nature and was not medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: According to the documentation submitted for review, the patient presented to the emergency department with a cough and headache. Her headache had commenced suddenly three days prior and was persistent. The sudden onset of headache that is not characteristic of a patients prior headaches is a red flag for a subarachnoid hemorrhage (SAH). Headaches from SAH are maximally painful at onset, then persist. A non-contrasted head CT is indicated to rule out hemorrhage. If this is normal, then a CT angiogram or lumbar puncture is indicated to rule out aneurysmal bleed, or sentinel hemorrhage. While this patient was determined not to have a hemorrhage, her presentation of acute persistent headache warranted emergent medical services. As such, the services provided were emergency medical services as defined by California lawFinal Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene expression profiling rendered for evaluation of the enrollees prostate cancer. Findings: Two physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision making in newly diagnosed patients considering active surveillance and in treated patients considering adjuvant therapy or treatment for recurrence. Patients with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. Genome-wide expression profiles of high-risk patients with prostate cancer who developed rapid metastasis after prostatectomy were compared with those of a matched cohort of men with favorable outcomes following surgery. From this, the Decipher, a 22-marker genomic classifier, based on RNA expression, was developed. In addition to the prediction of metastasis after prostatectomy, the genomic classifier has also been shown to be associated with progressive disease following salvage radiation. Given the current peer-reviewed medical literature, the gene expression profiling rendered 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 testing 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of an Ossatron Orthotripsy (orthotripsy) for the treatment of chronic right heel pain.  The health plan denied the enrollees request indicating that the requested orthotripsy is considered investigational.Three physician reviewers performed an experimental/investigational Independent Medical review.  Two of the three reviewers concluded that orthotripsy is not likely to be more beneficial for treatment of the enrollee's heel pain than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone ER 20 mg for treatment of the enrollees incomplete cervical spinal cord injury (SCI) due to trauma. Findings:  The physician reviewer found that The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. 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 anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested a wearable cardioverter defibrillator for evaluation of her medical condition status post myocardial infarction.   Findings:  Two physician reviewers found that studies including the DINAMIT trial reported by Gronefeld and colleagues assessing the use of prophylactic defibrillators have not demonstrated improved patient outcomes. Based on these trials a prophylactic wearable or implantable defibrillator is not considered an established standard in the medical community in this circumstance, in the absence of syncope, sustained ventricular tachycardia, or ventricular fibrillation. A prophylactic wearable external defibrillator would be indicated only if criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be delayed, or required explanation.  Based on the records provided, the patient is status post recent anterior myocardial infarction treated with coronary stenting. At that time, the use of the implantable cardioverter defibrillator would have been considered investigational and not likely to be more beneficial than standard therapy since the patient had no documented sustained ventricular tachycardia, no reported ventricular fibrillation or syncope, and had not waited at least 40 days to assess for an improved ejection fraction. Essentially, the criteria for placement of a prophylactic defibrillator in this circumstance appropriately required a period of time for verification of persistently decreased LVEF prior to defibrillator placement.   Based upon the information set forth above, I have determined the device at issue was not likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested autonomic nerve testing (CPT code 95924) for medical evaluation of his idiopathic peripheral autonomic neuropathy. Findings:  Two physician reviewers found that the records provided for review suggest this patient underwent a screening evaluation in the absence of any documented symptoms or medical disorder. Moreover, in the testing baseline information it indicates the patient has no symptoms. In the absence of clear cut autonomic neuropathic symptoms such as orthostatic hypotension, anhydrosis, or gastroparesis, automate autonomy nervous system testing was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.