Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a six-year-old male enrollee has requested Xolair injections (J2357) for treatment of the enrollees asthma.  Findings:  Two physician reviewers found that several, well-controlled, randomized clinical trials examining the efficacy of Xolair (omalizumab) in the treatment of poorly controlled allergic asthma in children six to 12 years of age have been published.  The study by Kulus and colleagues was a randomized controlled trial involving 246 patient who were six to 12 years of age. The authors noted that the addition of Xolair resulted in a statistically significant decrease in frequency of exacerbations and concluded that omalizumab was safe and well-tolerated in this patient population with severe persistent asthma treated with long-acting bronchodilators and inhaled corticosteroids.  An additional study by Lanier and colleagues enrolled 627 patients six to 12 years of age. This study demonstrated a decrease in frequency of exacerbations by 31% over 28 weeks and by 43% over 52 weeks.  This study also concluded that omalizumab was safe, well-tolerated and efficacious in this age group of asthmatics with poorly controlled symptoms despite available standard therapy. All told, is this patients case, Xolair injections are likely to be more efficacious than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female has requested a total abdominal hysterectomy for treatment of her uterine fibroids. Findings:  The physician reviewer found that there is no clear relationship between the patients fibroid and her bleeding, since the fibroid was not noted to be submucosal (in the uterine cavity). As noted in American College of Obstetricians and Gynecologists (ACOG) guidelines, uterine leiomyomata usually require treatment only when they cause symptoms, lead to urinary obstruction or appear to contribute to infertility. The ACOG guidelines note that not all bleeding is caused by leiomyomata, and other causes of abnormal bleeding in the presence of leiomyomata should be ruled out.  Based on the information provided, the patient has not undergone other workup to see if there is any other etiology for her abnormal bleeding.  Various hormonal and endometrial causes for abnormal bleeding exist; these require further assessment prior to a determination of the need for hysterectomy.   There are a number of conservative treatments to control abnormal uterine bleeding.  Only one oral contraceptive was tried by this patient, and often a low-dose continuous pill may cause abnormal bleeding itself. Other pills or regimens are available in this setting. Additionally, there is no evidence progesterone has been tried. Moreover, NSAIDs are often effective for menstrual cramps. The submitted documentation does not demonstrate that the patient has had adequate trials of conservative therapies or sufficient evaluation to rule out other causes of her symptomatology.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing to analyze how the body breaks down some drugs performed.  Findings:  The physician reviewer found that  genetic testing results may show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzymatic line. However, studies have shown that clinically useful predictors in genetic testing are limited for medication therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability. Moreover, there is a lack of large randomized trials have been conducted supporting its use. The existing studies have also indicated that there was no significant correlation between either genotypes or medication serum concentration and response treatment. Current evidence does not support the use of genotyping when choosing a medication, and even less is understood about its use in treatment. It lacks evidence based research to show efficacy in guiding the clinician towards choosing a medication regimen. Given these findings, the genetic testing to analyze how the body breaks down some drugs performed on was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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: Physician reviewer s 1, 2, & 3 are board certified in psychiatry 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: Upheld

The patient diagnosis of thoracic and lumbar segmental dysfunction. She has a long history of chronic upper and lower back pain. She was reportedly diagnosed with scoliosis as a child and hurt her back. She has been receiving therapy, chiropractic, and acupuncture. She reports that chiropractic care improves her symptoms and enables her to perform activities of daily living. Her provider states that chiropractic care helps the patient maintain functional capacity. She has been receiving chiropractic services about 20 times a year. She reports that when she is not seen, her pain level increases and she has difficulty with daily activities.The patient is receiving chiropractic care as maintenance therapy, which is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life; or therapy is that is performed to maintain or prevent deterioration of a chronic condition. Despite the claimant stating that she benefits from treatment, there is no new injury and she is receiving maintenance care. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature. As in this case, continued chiropractic treatment is considered maintenance therapy and is not medically necessary.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a board certified chiropractor and licensed in oriental 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: An enrollee has requested authorization and coverage for an ankle walking cast boot.The submitted documentation supports that the requested ankle walking cast boot is medically necessary. In this case, the patient was diagnosed with posterior tibial tendinitis on the right side. The patients initial treatment included a high CAM walking boot. The patient was noted to be obese, and he explained that not only did he have difficulty ambulating because of that fact, but he found that the originally dispensed high CAM walking boot was so heavy that he was unable to get his foot off of the ground to ambulate. The patient requested a lighter, low CAM walking boot. Both a high and a low CAM walking boot will immobilize not only the ankle joint but the subtalar joint, thereby reducing and/or halting motion of the posterior tibial tendon and allowing for healing. Under these circumstances, because of the patients comorbidities, an ankle walking cast boot is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested device 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 podiatric 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 48-year-old female has requested a breast MRI for evaluation of her right breast lump.  Findings:  Three physician reviewers found that the patient has a palpable abnormality in the right breast apparently increasing in size. Mammography showed very dense breast tissue and an ultrasound revealed a simple 3 mm cyst corresponding to the area of palpable concern. There is no known genetic predisposition to breast cancer in this patient. This patient has a palpable abnormality, which has been shown to be a simple cyst by ultrasound. If there is a clinical suspicion of breast cancer due to the increasing size and palpable nature of the mass, then a biopsy would be the best procedure to exclude malignancy. Although the patients breast tissue on mammography has been described as extremely dense, which limits the value of mammography there is no noted genetic predisposition. In this case, the request is for evaluation of a clinically suspicious palpable abnormality. Since there is still concern about the mass following ultrasound, a biopsy would be more beneficial than any other test for evaluation and possible treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested residential treatment care for the treatment of the enrollees mental health condition. Findings:  The physician reviewer found that an analysis indicates medical necessity for residential treatment existed. The factors in this case are consistent with CALOCUS and American Academy of Child and Adolescent Psychiatry practice guidelines. The patient had a history of high-risk behavior, the presence of major comorbid psychiatric disorders, a stressful recovery environment, conflict with parents, a need for ongoing multidisciplinary staff structure and interventions, and a need for careful medication monitoring.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral endovenous ablation therapy of the right and left perforator veins. The documentation does not support an indication for the requested bilateral endovenous ablation therapy of the right and left perforator veins for this patient. Based on the available documentation, the perforating vein reflux has not been fully assessed with lower extremity arterial perfusion to establish this as the source of the patients pain. Additionally, there has been no reassessment or follow-up studies described in the medical records regarding the patients response to the procedures already performed. As the risk-to-benefit ratio of perforator vein ablation is not as favorable as for saphenous vein ablation, perforator vein ablation is reserved for patients with recalcitrant venous ulcers or when the patients symptoms are directly attributable to the specific perforator vein to be ablated. For these reasons, the requested bilateral endovenous ablation therapy of the right and left perforator veins is not medically necessary for treatment of this patient.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 surgery with subspecialty certification in general vascular 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: Urgent Care
Decision: Upheld

The parent of a two-year-old female enrollee has requested emergency services for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the parents circumstances would believe the patient was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient had been experiencing mild to moderate cold/flu symptoms of one to two days in duration. The patients mother reported a fever, but it had resolved two days prior to the emergency department visit. The patient was not experiencing any shortness of breath or any vomiting. Her vital signs were normal and she was not in any acute distress. She did not require any medication in the emergency department or any prescription medications upon discharge. While the patients symptoms may have warranted a medical evaluation, they were not of sufficient severity to cause a prudent layperson to believe the patient was at risk of serious jeopardy to her health, serious impairment to bodily function or serious dysfunction of a bodily organ or part. Thus, this patients symptoms did not meet the criteria for an emergency medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee has requested acute inpatient psychiatric treatment for treatment of her major depressive disorder, severe, eating disorder, not otherwise specified, post-traumatic stress disorder and obsessive-compulsive disorder. Findings:  The physician reviewer found that in this patients case, acute inpatient psychiatric treatment is medically indicated.  Per the submitted documentation, there is the presence of suicidal ideation with a specific plan and high suicidal intent. Per American Psychiatric Association guidelines, acute inpatient psychiatric treatment is indicated in this clinical situation. The most recent medical notes indicate ongoing concerns regarding the patients safety.  This patient cannot be safely and effectively treated at a lower level of care. All told, the medical necessity of the requested acute inpatient psychiatric treatment has been established by the submitted documentation.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested Euflexxa injections for treatment of her knee osteoarthritis. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to Goldberg and Goldberg, Although several randomized controlled trials have established the efficacy of this treatment modality, additional high quality randomized control studies with appropriate comparison are still required to clearly define the role of intra-articular HA injections in the treatment of osteoarthritis. While there have been some studies suggesting Euflexxa injections may be efficacious for the treatment of osteoarthritis, there is a lack of adequate randomized, controlled studies demonstrating continued use of Euflexxa injections are effective. In the absence of such evidence, Euflexxa injections are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female with multiple sclerosis and generalized muscle stiffness. She also has chronic neck pain and stiffness. She has failed physical therapy and is now seeking authorization for massage and aquatic therapy. The Health Plan has denied authorization for the requested therapies.The Health Plans denial should be upheld. Massage therapy is not medically indicated for this patient. Although it may provide short-term passive pain relief, it will not improve or benefit the patients condition in the long-term. Likewise, aquatic therapy is unlikely to provide improvement in the patients condition particularly in a patient such as this who underwent, tolerated, and failed traditional physical therapy. Because there is no evidence the requested therapies would provide sustained benefit for this patients condition, I have determined the requested therapies are not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male enrollee has requested  speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that in this patients case, he has received 8-10 hours per week of individual and group speech therapy since 2011. The patient was 4-5 years old during the period of the disputed services. Although the CELF testing has confirmed significant improvement over the period of intensive speech therapy, the hours of therapy were excessive, particularly as the patient was developing sentences by age 212 which suggests less than severe impairment. Most recommendations for speech therapy for autistic children are for 1 to 2 hours per week of individual speech therapy. By the beginning of the disputed period, the patient had received 50 speech therapy sessions in 2012. Based on this patients deficits during the disputed period, 1 hour per week of individual speech therapy was medically necessary from the remainder of the speech therapy services provided during this period were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gammaCore Sapphire non-invasive vagus nerve stimulator (VNS). Findings:  The physician reviewer found that integrating new migraine treatments into clinical practice states that, neuromodulation may be appropriate for preventive and acute treatment, depending on the needs of individual patients. Neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy. Non-invasive neuromodulation, which alters neural activity through the stimulation of nerves or neural tissue, includes the gammaCore system. The FDA approved gammaCore for the acute treatment of migraine and episodic cluster headache. Mwamburi and colleagues reviewed the evidence of noninvasive VNS for treatment of migraine. The authors concluded that, patients with migraine who experience two or more headache days per month and remain dissatisfied with their current treatment are the best candidates to try gammaCore. In this case, the patient has migraine headaches that have increased in frequency despite treatment with multiple abortive and preventative medications. She is planning to become pregnant which affects her choice and intake of migraine medications. She has tried gammaCore in the past which resulted in improvement in migraine frequency. Based on the AHS position statement and current studies, gammaCore is likely to be more beneficial for the treatment of this patients migraines than available standard therapies. All told, the requested gammaCore Sapphire non-invasive VNS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested gammaCore Sapphire non-invasive VNS is 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 services are 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: 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: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested a sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Two physician reviewers found that there is a large and growing number of publications pertaining to this procedure as discussed by Deitel and colleagues who determined that sleeve gastrectomy (SG) is a rapid and less traumatic operation than alternatives. Deitel continues that the SG procedure has thus far shown a good resolution of comorbidities and good weight loss if a narrower channel is constructed than for the duodenal switch. Nocca and colleagues obtained good results in patients with laparoscopic sleeve gastrectomy (LSG) in terms of both weight loss and morbidity.
Appeal type: Medical Necessity
Decision: Overturned

: The patient has requested authorization and coverage for Chantix tablet and cardiac rehabilitation. Based on the records provided for review, this patient underwent percutaneous coronary revascularization in May 2019. In this circumstance of coronary revascularization within the last six months, cardiac rehabilitation is considered the standard of care (Balady, et al.). In addition, the patient has ongoing smoking with documented inability to quit using multiple modalities other than Chantix medication. Since there is an improved smoking cessation rate using Chantix and the patient has failed other approaches to quitting smoking, Chantix tablet is indicated (Patel and Steinberg). All told, the requested Chantix tablet and cardiac rehabilitation are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and 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 internal medicine with subspecialty certification in cardiovascular 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