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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for in-home private during nursing home services. Kuo and colleagues noted that the parents of medically complex children with special health care needs spend an average of nearly nine hours per day managing the patients basic healthcare needs, such as personal hygiene and feeding, administering drugs and managing symptoms, pain and sleep related problems during the night. Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the patients care. It is important for patients families to receive appropriate support with daily care tailored to the patients individual needs. In this case, this patient has multiple chronic conditions and functional limitations that make her dependent on caregivers and the use of complex medical appliances. This patients mobility, breathing, and feeding problems require constant assistance to cope with her functional limitations. For these reasons, the requested in-home private during nursing home services are 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for in-office phototherapy. Sidbury and colleagues report that despite its relapsing and remitting nature, the majority of patients with atopic dermatitis (AD) can achieve clinical improvement and disease control with nonpharmacologic interventions such as emollient use, conventional topical therapies, including corticosteroids and calcineurin inhibitors, and environmental and occupational modifications, when necessary. The authors note that phototherapy is recommended as a treatment for both acute and chronic AD, after failure of the measures mentioned above. The authors further note that there are no studies to date that document the efficacy or safety of home light therapy for patients with AD or contrast its use with in-office phototherapy. In this case, given that the patient has failed first line treatment with topical emollients and steroids, the requested service is medically indicated. Therefore, in-office phototherapy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 43-year-old female enrollee has requested authorization and coverage for a repeat epidural injection for treatment of the enrollees low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested repeat epidural injection in this patients case.  The peer-reviewed medical literature does not support the requested service for the treatment of this patients medical condition.  Novak and Nemeth performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections, to help determine what sort of responses should occur to repeat an injection, and to outline specific research needs in these areas.  The authors found that there was limited evidence to suggest guidelines for frequency and timing of epidural steroid injections or to help define what constitutes the appropriate partial response to trigger a repeat injection.  Abdi and colleagues reported that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief.  Given that the patient did not experience long-term relief (greater than three months), or demonstrate reduced use of medications and adjunctive therapy (physical therapy, heat and ice) with the first two epidural injections, a repeat epidural injection is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee requested a dopamine transporter single photon emission computed tomography (SPECT-DaT) scan for medical evaluation of her Parkinsons disease.  Findings:  Two physician reviewers found thatSPECT-DaT scans have been shown to be useful in cases where the diagnosis is not definitive on clinical grounds. Such is in this case where the patients neurologist suspected a possible essential tremor (or other tremor disorder). It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are different and the treatments for Parkinsons disease can have significant side effects. In this case, the patients diagnosis was confirmed using this study and the patient was able to be appropriately counseled and placed on Parkinsons disease therapy in a timely fashion. All told, the diagnostic procedure was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her breast examination. Findings:  Two physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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: Upheld

The patient has requested authorization and coverage for Linzess 72 mcg twice a day. The American Gastroenterological Association medical position statement on constipation states, We suggest a gradual increase in fiber intake, as both foods included in the diet and as supplements and/or an inexpensive osmotic agent, such as milk of magnesia or polyethylene glycol. Depending on stool consistency, the next step may be to supplement the osmotic agent with a stimulant laxative (e.g., bisacodyl or glycerol suppositories). In this case, the patient has failed an osmotic laxative, MiraLAX, but has not attempted other laxative classes recommended by the American Gastroenterological Association before the use of advanced pharmaceutical laxatives such as Linzess. The medical evidence does not support the requested medication in this clinical setting. Therefore, Linzess 72 mcg twice a day 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 internal medicine with sub-specialty certification in gastroenterology 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 parent of an enrollee has requested authorization and coverage for general anesthesia for treatment of the enrollees dental condition.Findings:  The physician reviewer found that general anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice.  General anesthesia is often employed to facilitate extensive dental treatment, particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting.  The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for some pediatric patients.  Because dental restoration under general anesthesia does not require cooperation from the child, it is a very efficient treatment modality.  It can usually be completed in one procedure.  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 anesthesiology with sub-specialty certification in pediatric anesthesiology 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

An enrollee has requested authorization and coverage for the medication Harvoni for 12 weeks. Guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommend treatment for all patients who have hepatitis C. Benefits from early therapy have been demonstrated, and these definitive guidelines no longer suggest that treatment should be a function of the presence of liver damage. The AASLD/IDSA guidelines note, More importantly, from a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C eradication. Therefore, the panel continues to recommend treatment for all patients with chronic hepatitis C infection, except those with a short life expectancy that cannot be remediated by hepatitis C treatment, liver transplantation, or another directed therapy. The selection of Harvoni is also appropriate according to these guidelines. Therefore, the requested medication, Harvoni for 12 weeks, is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for single photon emission computed tomography dopamine transporter (SPECT-DAT) scan.  Examination showed a resting tremor, mild cogwheel rigidity of the right arm and slower fine motor function of the right hand. The neurologist ordered magnetic resonance imaging (MRI) of the brain and a Single Photon Emission Computerized Tomography Dopamine Transport (SPECT-DAT) scan to clinically establish a diagnosis. The SPECT-DAT scan was positive for dopaminergic abnormality. These results were consistent with Parkinsons disease. Findings:  The physician reviewers found that according to practice guidelines, clinical indications for SPECT-DAT for the evaluation of movement disorders include differentiation of parkinsonian syndromes (PS) from essential tremor in patients with worsening symptoms and diagnostic confirmation when diagnostic uncertainty exists. An accurate diagnosis of PS is critical for clinical management; misdiagnosis can occur in up to 10% of cases. This can lead to unnecessary disability or inappropriate treatment. SPECT-DAT can reliably distinguish patients with Parkinsons disease (PD) and other parkinsonian syndromes associated with nigrostriatal degeneration. It is considered reasonable for patients in whom the diagnosis is unclear after clinical evaluation. It was approved for striatal dopamine transporter visualization to assist in the assessment of adult patients with suspected parkinsonian syndromes. Final Result: Two of the three reviewers determined that the requested services are 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 neurology 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

A 55-year-old female enrollee has requested for partial breast irradiation using MammoSite brachytherapy for treatment her breast cancer. Findings:  Three physician reviewers found that partial breast irradiation with MammoSite is safe and effective when used to treat women with low risk breast cancer, there is insufficient data to support that it is superior to whole breast irradiation for patients.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested reimbursement for general anesthesia in a hospital operating room setting during dental extraction surgery. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees impacted teeth. A review of the records indicates the enrollee was diagnosed with impacted teeth. In an operative report, the enrollees provider noted that the enrollee had a disturbance of tooth eruption involving the secondary maxillary canines. The maxillary canines were horizontally impacted with crowns facing anteriorly. The roots of the adjacent teeth were close to the impacted teeth. The provider noted the procedure would be carried out in an operating room under general anesthesia due to the enrollees age and significant complexity of the procedure. The enrollee was 12-years-old at the time of the procedure. The enrollees provider recommended general anesthesia during a dental extraction surgery for the enrollee.Per Medi-Cal guidance  cited here as persuasive, non-binding authority  patient selection for conducting dental procedures under general anesthesia utilizes medical history, physical status, and indications for anesthetic management. General anesthesia can be considered only after consideration has been given to behavior modification, local anesthesia and then conscious sedation. Patients with severe asthma should be treated in a hospital setting capable of responding to a serious medical crisis.In this case, there is a well-documented need for general anesthesia. According to the treating physician, hospital-based general anesthesia was necessary because it would not have been safe to sedate this patient in an office setting while performing the complex surgical procedure. Additional documentation indicates the patient required surgical treatment that cannot be rendered under conscious sedation. Per the treating physician, this patient also suffers from severe asthma and thus needed to be treated in a hospital setting equipped to handle an emergency. Per California guidelines, criteria for general anesthesia have been met. Therefore, the general anesthesia provided during dental surgery performed was medically necessary.Final Result: The reviewer determined that the requested service was 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 anesthesiology with subspecialty certification in pediatric anesthesiology, 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 reimbursement for wearable cardioverter defibrillator vest received. Findings:  The physician reviewers found that there is a lack of support for the device at issue in this clinical setting.  The benefits of the wearable cardiac defibrillator have been the subject of intensive study.  The wearable cardiac defibrillator has not been proven to be of benefit for newly-diagnosed cardiomyopathy.  The American College of Cardiology (ACC) guidelines do not support use of the wearable cardioverter defibrillator vests in this clinical setting.  Permanent implantable cardioverter defibrillators are recommended after a waiting period of 45 to 90 days, but the wearable cardioverter defibrillator has not been proven beneficial.  There is a lack of evidence via randomized trials showing benefit for wearable cardioverter defibrillators over and above that of optimized medical therapy.  Thus, the superior effectiveness of the wearable cardioverter defibrillator vest received has not been demonstrated. Final Result: 2 of 3 reviewers determined that the device at issue was 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 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 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 extracorporeal shockwave therapy (ESWT). The documentation reviewed states that this patient has a history of left heel pain 15 years prior that was treated successfully with conservative care and orthotics. Recently, the patient underwent conservative care over four months for plantar fasciitis. The treating provider noted that the patients left heel pain was almost resolved, which suggests that conservative treatment has been at least partially effective. The patients provider has recommended treatment with ESWT. However, the current research to support ESWT has been inconclusive. Gollwitzer and colleagues assessed 246 patients who received either ESWT or placebo. The authors noted 69.2% improvement with ESWT compared to 34.5% improvement with placebo, with only minor complications. The authors concluded that further studies should focus on resolution of inconsistencies in treatment protocols. All told, the requested ESWT is not likely to be more beneficial for the treatment of the patients medical condition then available standard therapy.Findings:  Two of the three physician reviewers found the requested ESWT is not likely to be more beneficial for the treatment of the patients medical condition then available standard therapy.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: Physician reviewer 1 is a licensed D.P.M., board certified in podiatry and is actively practicing. Physician reviewer 2 is a licensed D.P.M., board certified in podiatry and is actively practicing. Physician reviewer 3 is a licensed D.P.M., board certified in podiatry 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

A 55-year-old female enrollee has requested for Xifaxan (rifaximin) for treatment of her Clostridium difficile colitis. Findings:  The physician reviewer found that there is sufficient evidence in the medical literature to support the use of Xifaxan in patients with C. difficile colitis. If left untreated, this disease can result in serious consequences and lead to recurrent hospitalizations and/or surgery.