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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 mg, quantity 270, every 30 days, and morphine ER 30 mg, quantity 30, every 30 days. The submitted documentation does not support that the requested medication regimen is medically necessary. Records reflect that the patient is on high dose opiate therapy for non-malignant pain. The use of anti-Paget Disease agents is not documented, and opiates are not appropriate to treat the pain of Paget's Disease. Furthermore, the rationale for continuing opiates as presently requested is not consistent with clinical practice guidelines as set forth in the CDC Guideline for Prescribing Opioids for Chronic Pain--United States. Under these circumstances, the request for Norco 10/325 mg, quantity 270, every 30 days, and morphine ER 30 mg, quantity 30, every 30 days, is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication regimen 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 subspecialty certification in pain management. 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 breast reduction surgery. In the medical literature, researchers noted that patients with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. Per the American Society of Plastic Surgeons (ASPS), at least two quality of life signs are required to support an indication for breast reduction surgery. This patient meets the ASPS criteria given the documented presence of back, shoulder, and neck pain, with documented severe shoulder grooving. The two quality of life signs meet the ASPS criteria for breast reduction surgery. For these reasons, the requested breast reduction surgery is medically necessary for 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. Applying the California reconstruction statute, this patient has pain in the neck, shoulders, and lumbar spine, and she reports decreased ability to sleep and perform activities of daily living due to her condition. In this patient, the proposed resection of at least 1500 grams per breast. This supports that the requested breast reduction surgery will improve the patients function and create a more normal appearance. Therefore, the requested breast reduction surgery is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that Botox is not a first-line therapy for migraine or chronic headaches, there is medical literature supporting its use for chronic intractable headaches. The literature regarding Botox demonstrates that is well tolerated, generally without systemic side-effects. Adverse effects are generally mild to moderate in severity. The most recent and largest studies show the benefit of Botox use in patients with chronic headaches. Thus, there is adequate evidence that Botox can be useful in a subset of migraine patients who have tried and failed multiple standard preventive agents. In this patients particular case, she had tried (and failed) many first-line therapies to treat her migraine headaches. It is not likely that further treatment attempts with standard migraine preventive medications are likely to of benefit. Therefore, she is an appropriate candidate for treatment with a secondary agent, such as Botox.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy every two weeks. The records provided for review document that this patient has a history of chronic inflammatory demyelinating polyneuropathy (CIDP). The patient has been stable on IVIG without side effects. Previous attempts to stop IVIG resulted in relapses requiring hospitalizations. Given these findings and the current medical literature, the requested IVIG therapy every two weeks is supported as medically necessary for treatment of this patients CIDP. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

The parent of a 7-year-old male enrollee has requested 25 hours of applied behavioral analysis therapy per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that upon reviewing the medical literature, there are numerous studies addressing the functional benefits of ABA therapy. When ABA therapy was first initiated, some providers recommended that 40 hours per week was indicated but this was later reduced to 20 hours per week as a result of the burden of the intensity that the therapy puts on families and service providers. Since that time, additional studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (more than 20 hours per week) to further assess the outcome relative to additional hours of treatment. In addition, studies have been conducted to address the need for intensive behavior therapy versus standardized care. Overall, the scientific data is supportive of the utility of behavioral therapy and suggest that patients who receive this treatment show a statistical improvement in cognitive, language and adaptive behavior skills when compared to patients who were untreated. However, Spreckley and Boyds meta analysis of the literature found that appropriately powered clinical trials with broader outcomes are still needed to fully establish the role of ABA in managing young patients with ASD. The authors cited a study by Roberts, et al. which determined that for best results, a minimum of 20 hours per week of intervention over 2 years, taking into account of each patients strengths and weaknesses and family circumstances, is essential for young patients with ASD to make gainsWhile there is no literature specifically addressing the utility of 25 hours per week of ABA therapy, there is support for high intensity therapy of at least 20 hours per week. Therefore, based on the clinical documentation provided as well as review of the relevant scientific evidence, there is adequate support for 20 hours of ABA therapy per week for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested for replacement compression socks every three months for treatment of the enrollees lymphedema. Findings:  The physician reviewer found that the compression socks that are prescribed to the patient are guaranteed to maintain compression for six months and her symptoms have remained stable with use of the compression socks. Further techniques to lengthen the cosmetic appearance of the garments have been recommended within physical therapy. Given that the compression of the socks are not compromised prior to the six month period and that the company providing the socks will replace the garments if the compression fails prior to the six month period, it is not medically necessary for the patient to receive replacement compression socks every three months.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee has requested authorization and coverage for brachytherapy. There is sufficient support for the requested services in this clinical setting. The records document that the patient has intermediate risk prostate cancer. Since his life expectancy is greater than 10 years, brachytherapy is a standard of care. Per the National Comprehensive Cancer Network guidelines, brachytherapy is a standard of care for men with intermediate risk prostate cancer and a life expectancy greater than 10 years. The medical evidence supports the requested services in this patients case. Therefore, brachytherapy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are 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 sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for vedolizumab (Entyvio) injections. Current American College of Gastroenterology Clinical Guidelines for the management of Crohn's disease support the use of vedolizumab prior to alternatives. In this case, the patient has diagnosed pouchitis and Crohns disease, and he has had an inadequate response to standard therapies. There is also a reasonable concern that anti-TNF medications would be more likely to cause immune suppression and put the patient at risk for serious infection. Under these circumstances, vedolizumab (Entyvio) injections are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Spinraza. Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons. The disease poses significant adverse outcomes in the affected patient population. Survival motor neuron 1 (SMN1) protein encoded by the SMN1 gene is critical for survival and the functioning of motor neurons. An almost identical gene, survival motor neuron 2 (SMN2), is present on the same chromosome but produces a truncated protein. The number of copies of the SMN2 gene in a patient determines the severity of disease, as fewer copies suggest the presence of more severe disease. Spinraza is U.S. Food and Drug Administration (FDA) approved for the treatment of child and adult patients with SMA. Clinical trials have demonstrated the safety and efficacy of Spinraza. One study reported such favorable results in the interim analysis that all of the patients were transitioned to receive Spinraza in an ongoing open-label, phase 3 study. This patient has a diagnosis SMA with zero copies of SMN1 and three copies of SMN2. She has not been able to crawl, sit, or walk independently. Given the current support in the medical literature, Spinraza is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with expertise in neurodegenerative diseases 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: A male enrollee has requested reimbursement for the Optune tumor treatment fields therapy. As noted in the medical literature, the Optune device is a wearable, noninvasive medical device designed for continuous use throughout the day by the patient. The device has been shown in both in-vitro and in-vivo studies to slow and reverse tumor growth by inhibiting mitosis, the process by which cells divide and replicate. There are studies reporting positive results with use of the Optune device in patients with glioblastoma multiforme. In addition, there is no evidence of cumulative damage to healthy tissue when exposed to tumor treatment fields therapy. For these reasons, the Optune tumor treatment fields therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Optune tumor treatment fields therapy was 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 services at issue were 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:  One reviewer is board certified in neurosurgery and is actively practicing. One Reviewer is board certified in neurosurgery and is actively practicing.  One Reviewer is board certified in neurosurgery 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryosurgical ablation of the lung. The submitted documentation fails to demonstrate the medical necessity of the requested services. A recent meta-analysis by researchers assessed survival and quality of life in advanced-stage non-small cell lung cancer patients receiving cryoablation. The results showed that cryoablation can improve the quality of life in this group of patients, and that chemotherapy or radiotherapy do not have clinical advantages over cryoablation alone. However, in this enrollees case, the enrollee has not been determined to have advanced stage or intermediate stage non-small cell lung cancer. The enrollee has an indeterminate lung nodule which has not been biopsied or resected. The lesion is of uncertain significance. Cryotherapy is not recommended as superior to resection for lesions which are otherwise amenable to local resection. Current National Comprehensive Cancer Network (NCCN) guidelines do not support cryotherapy for this indication. Cryotherapy treatment protocols and indications have not been universally established for early stage lung cancers. Therefore, cryosurgical ablation of the lung is not medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a neurosurgeon. This patients computed tomography (CT) scan of the head report did not demonstrate a brain bleed and magnetic resonance imaging (MRI) did not reveal any foraminal or central canal stenosis. However, the CT scan of the head did show a mega cisterna magna versus arachnoid cyst midline posterior fossa. An arachnoid cyst is an abnormal mass in the brain that can be symptomatic causing brainstem and cerebellar compression with symptoms such as gait disturbance and headaches. When arachnoid cysts are identified and reported to be symptomatic, the special knowledge and training of a neurosurgeon is needed to properly scrutinize the patients imaging studies, evaluate the history and perform a physical examination, in order to determine if the findings on the CT scan demonstrate a symptomatic lesion. For these reasons, the requested referral to a neurosurgeon is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurosurgery 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 57-year-old female enrollee has requested vagus nerve stimulation therapy (VNS) for the treatment of her depression. Findings:  Three physician reviewers found that to date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research-centered, clinically-based and reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of the established principles of health care practice for the management of refractory depression. VNS remains an experimental, controversial and unproven therapy at this time. It has not been accepted by the psychiatric community as routine treatment in the management of refractory depression.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. 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 authorization and coverage for Vemlidy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases recommend alternatives for the treatment of chronic hepatitis B.  As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy is medically necessary for the treatment of this patients hepatitis B. Final Result: The reviewer determined that the medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested additional physical therapy visits for the treatment of his coccydynia and tarsal/tunnel syndrome. Findings:  The physician reviewer found that although at the initial phase of this patients treatment his PT would have required the unique skills and training of a physical therapist for educational purposes, such a requirement would not extend past a reasonable period of time within which an IEP could be established. Therefore, at this time the unique skills and training of a physical therapist are not medically necessary. The medical records do not support any specific future PT treatment plan which would continue to require the unique education and skills of a physical therapist. Thus, at this time the skilled PT component of the patients treatment is no longer necessary and the PT can be performed via an independent home exercise program (IEP) by the patient.