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

An enrollee has requested authorization and coverage for Cuvitru 35 Gram weekly subcutaneous infusions. For patients with autoimmune polyneuropathies, the rate of disability improvement has been significantly higher in those treated with immunoglobulin replacement therapy than in those treated with placebo, and changes can be seen as early as one month after the initiation of therapy. There are many years of evidence in peer reviewed journals demonstrating benefit from immunoglobulin replacement therapy in autoimmune polyneuropathies. In this case, the patient has been diagnosed with autoimmune autonomic polyneuropathy and has significant and disabling symptoms that prevent her from performing her activities of daily living. Records also reflect that the patient has demonstrated insufficient response to conservative therapies. Under these circumstances, the requested Cuvitru 35 Gram weekly subcutaneous infusions are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine and allergy and immunology 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 male enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder. However, the recommendation does not yet extend to bipolar disorder.  Moreover, it does not appear that the patient has failed other treatments commonly relied upon to treat bipolar disorder.  It is unclear if the patient has completed an evidence-based therapeutic intervention for bipolar illness such as cognitive behavioral therapy, family therapy or interpersonal/social rhythm therapy. In conclusion, based on the documentation provided within context of current practice guidelines and relevant peer-reviewed literature from the scientific community, the requested TMS therapy is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One (hyaluronan) injections. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A systematic review was conducted of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, Synvisc One (hyaluronan) injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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 orthopedic 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 patients parent has requested reimbursement for residential treatment center (RTC) services. Applying the CALOCUS framework, the patient met the criteria for the RTC services. The patient was at serious risk of harm (score 4) due to significant impulsivity and poor judgment and insight. The patients behavioral issues were significantly endangering to him as evidenced by suicidal threats and recent self-harm, as well as excessive substance use. The patient demonstrated moderate functional impairment (score 3) given his conflict with his parents, as well as recent gains made while in the structured environment of the RTC. The patient has significant comorbidities (score 3) considering his history of depression and anxiety as well as substance abuse. The patients recovery environment was moderately stressful (score 3) as the records report ongoing conflict with his family and possible abuse, bullying by peers, and struggles with parental expectations. The patients recovery environment was supportive (score 2) as his parents were active participants in his treatment and treatment planning. The patient has exhibited poor response to treatment (score 4) due to a lack of response to outpatient treatment and psychiatric hospitalization, as well as turmoil and distress caused by developmental pressures. The patients parents were constructive with treatment (score 2) given their participation in the patients treatment. This gives the patient a composite score of 21, which is consistent with medically monitored community based services. Due to a score of 4 on risk of harm, the patient qualified for Level Five, medically monitored residence based services. Furthermore, the patient met the requirements for Level 5B, intermediate stay medically monitored residence based services due to impulsivity and recent suicidal ideation, gains made in a structured setting, conflict with parents, co-occurring mental health and substance abuse, and lack of response to previous treatment. The typical length of stay at this level of care is up to 60 days. The patients stay at the RTC falls well below this upper limit. For these reasons, the RTC services were medically necessary for 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 with subspecialty certification in child and adolescent 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reduction mammaplasty for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the requested services.  This patient has documented chronic pain of the neck, back, and shoulders. Her examination is consistent with significant macromastia. Conservative management has included NSAIDs, multiple bras, pain injections to the neck and back, as well as physical therapy.  Based on the overall clinical documentation, the patient has failed conservative management over many years.  Her condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. This patient has a functional problem that is directly related to her significant macromastia. Breast reduction is a well-known procedure that directly addresses this functional deficit. Thus, the requested reduction mammaplasty is medically indicated for the 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 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

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that at issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The digital breast tomosynthesis performed was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: The reviewers determined that the 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: the physician reviewer numbers 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prothrombin G20210A (factor II) mutation testing. Findings:  The physician reviewer found that there is a lack of support in evidenced based literature for the services at issue in this clinical setting. Unselected population based screening for inherited thrombophilia is not recommended because of low frequency of the symptomatic condition in the general population, and the low penetrance of the symptomatic condition among carriers of the most common thrombophilic conditions specifically, factor V Leiden and prothrombin G20210A mutations. In addition, a safe, long-term method of prophylaxis, if an abnormality is found, is lacking. While patients with a family history of thrombosis are at increased risk for a mutation, a simple positive history is not a reliable criterion to select patients for screening. The documentation provided for this review do not support a significant personal history nor a family history of thrombosis. Consumptive coagulopathy related to the angiolipomas does not necessitate factor II mutation testing. For these reasons, prothrombin G20210A (factor II) mutation testing was not likely to have been more beneficial than the available modalities of evaluating this patient. Final Result: All three reviewers determined that services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in hematology 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 48-year-old female has requested ProDisc-L lumbar artificial disc surgery for treatment of her recurrent low back pain and primarily left L4 radiculopathy.   Findings:  Three physician reviewers found that the patient has a history of low back pain that radiates into the left buttock and posterior and lateral thigh. She currently has minimal symptoms but is unable to predict when she will have an exacerbation of her pain. She has had multiple chiropractic treatments, laser therapy, and pain management injections all without complete relief of her symptoms. Her neurological examination is within normal limits. An MRI of the lumbar spine shows a left paracentral disk bulge at the L4-5 level with foraminal stenosis. An electromyography/nerve conduction study (EMG/NCS) of the lower extremities was normal but a provocative discogram performed at the L4-5 level was concordant. At this time, her provider has recommended ProDisc-L lumbar artificial disc surgery. The ProDisc-L Total Disc Replacement was approved by the FDA in 2006 for spinal arthroplasty in patients with degenerative disc disease. This approval was based on a non-inferiority rather than superiority study comparing 162 randomized patients treated with ProDisc-L and 80 control patients. The authors concluded that at 24 months, the overall incidence of adverse events occurring in the ProDisc-L group, the number of device-related adverse events, and overall success rate of the ProDisc-L group was no worse than that of the control group, with a non-inferiority margin of 10%, using FDAs criteria for overall success. The results of this trial were published in 2007 but there were unexplained discrepancies in the number of subjects reported upon when compared to the number presented to the FDA (Zigler, et al). There have not been any other randomized controlled clinical trials published to date. The FDA has required a post-approval study to obtain a total of five year follow-up data from all subjects in the clinical study. In one case series study with longer follow-up, Shim and colleagues followed 24 patients for greater than 3 years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients (32% and 28.6%, respectively). This raises concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease. Given the overall lack of published long-term (greater than two years) safety and efficacy data, lumbar disc replacement is not likely to result in an improved health outcome when compared with standard alternative treatments.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for Botox. Botulinum toxin (Botox) is a potent muscle relaxant which has been found to have analgesic effects in patients with a variety of pain syndromes. Overall, clinical trials have confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine. Moreover, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of migraine. In addition, there have been several studies that have reported that Botox injections are also effective for chronic daily headache and migraine in children and adolescents. This patient has failed treatment with numerous therapies including a tricyclic antidepressant medication, cyproheptadine, and an anticonvulsant, physical therapy, occipital nerve blocks with lidocaine, and massage. Acute abortive medications have included: ibuprofen; acetaminophen; almotriptan; rizatriptan; and sumatriptan, all of which were ineffective. DHE was given for three days without benefit. Given the support in the medical literature, the requested Botox is medically necessary for treatment of this patients migraine. Botox is a potent muscle relaxant which has been found to have analgesic effects in patients with a variety of pain syndromes. Overall, clinical trials have confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine. Moreover, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of migraine. In addition, there have been several studies that have reported that Botox injections are also effective for chronic daily headache and migraine in children and adolescents. This patient has failed treatment with numerous therapies including a tricyclic antidepressant medication, cyproheptadine, and an anticonvulsant, physical therapy, occipital nerve blocks with lidocaine, and massage. Acute abortive medications have included: ibuprofen; acetaminophen; almotriptan; rizatriptan; and sumatriptan, all of which were ineffective. Dihydroergotamine (DHE) was given for three days without benefit. Given the support in the medical literature, the requested Botox is medically necessary for treatment of this patients migraine.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 pediatrics and neurology with special qualification in child neurology 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

The parent of a female enrollee requested residential treatment services for medical treatment of the enrollees polysubstance abuse.  Findings:  The physician reviewer found that the records available for review do not show that criteria were met for admission to the residential level of care. The patient was not a danger to herself or others. She had not failed substance abuse treatment at a lower level of care. She was medically stable and did not receive any further changes in her psychiatric care. She did not receive any medical or nursing care that required 24-hour monitoring. All told, RTC services were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient substance abuse treatment. Findings: The physician reviewer found that the submitted documentation failed to demonstrate the medical necessity for the services at issue in this clinical setting. The Level of Care Utilization System (LOCUS) criteria is a method used to objectively determine if a patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for adults. There is no documentation of a history of any suicide attempts. The patients medical/addictive/psychiatric co-morbidity was a 3, significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, marijuana use disorder, ADHD, generalized anxiety disorder, sexual addiction, and major depressive disorder. The patient will continue to use substance despite negative consequences. His recovery environment was also a 3, moderately stressful environment. The patient has limited support at this time. His support revolved around professional resources and community sponsors. Treatment history was a 3. The patient has an unclear response to treatment and ability to maintain a significant recovery. Engagement and recovery status was a 2, positive engagement and recovery. The patient was motivated for recovery and was compliant with treatment recommendations.  According to the LOCUS criteria, this patients total score is 19. The patient continued to need treatment for his alcohol use disorder, marijuana use disorder, sexual addiction, ADHD, generalized anxiety disorder, and major depressive disorder. However, based on the LOCUS criteria, the patient could have been treated at a less restrictive environment like an intensive outpatient program.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. 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: An enrollee has requested authorization and coverage for Psychological Testing. Findings:  The physician reviewer found that sychological testing is to be used in conjunction with other sources of clinical information to create a diagnostic formulation and treatment recommendations. These multiple sources of clinical information include clinical interview, interviews with collateral sources, self-report objective measures, observation of the patient, and review of past records. The appropriate use of psychological and neuropsychological testing is to assist in narrowing the differential diagnosis when there is a lack of diagnostic clarity or a lack of progression in a patients treatment plan due to possible functional and cognitive limitations, which are not able to be elucidated in the course of clinical interview and treatment.In this case, while the patient has requested psychological testing for the purpose of diagnosing or treating a condition and its symptoms, the present request is for psychological testing in the absence of other sources of clinical information. APA Guidelines establish that psychological testing is to be used in conjunction with other sources of clinical information to create a diagnostic formulation and treatment recommendations. These other sources of clinical information include clinical interviews, interviews with collateral sources, self-report objective measures, observation of the patient, and review of past records. The submitted documentation, however, indicates that the patient has not previously participated in therapy and that her care to date has been limited to a single intake interview with a psychologist. There has therefore been no documented, full clinical evaluation performed to date that is based on clinical interviews, interviews with collateral sources, self-report objective measures, observation of the patient, or review of past records. There is also no diagnostic lack of clarity that is informed by any such clinical information. Psychological testing under these circumstances is not in accordance with the generally accepted standards of mental health care. Accordingly, the requested Psychological Testing is not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the requested services are not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.