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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for a custom cranial remolding orthotic. Positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes may include the resting of the fetal head against a hard surface, such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy, for a prolonged period, while postnatal causes are more common and may include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep positions. Presentation ranges from mild or moderate cases, that may respond to mechanical adjustments and exercises, to severe cases that are refractory to repositioning and may require surgery for correction. Jung and Yun note that conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Current treatment of mild head shape abnormality includes repositioning, physical therapy, and increased time in the prone position. Cranial orthoses are recommended for infant patients with moderate-to-severe skull deformity due data in current medical literature showing the long-term distinct benefits from helmeting when compared to repositioning. In a longitudinal cohort study design comparing helmeting with repositioning by following 100 infants with deformational plagiocephaly and/or brachycephaly for ten years, Naidoo and colleagues concluded, Infants will have more improvement in head shape with a helmet than with repositioning. The Congress of Neurological Surgeons guideline on the role of cranial molding orthosis, or helmet, therapy for patients with positional plagiocephaly states, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). In this case, the patient has a combination of moderate to severe plagiocephaly and moderate-to-severe brachycephaly, exacerbated by torticollis. Given the severity of this patients head shape abnormality and his failure to show improvement with repositioning, exercises, and stretching, treatment with a cranial remolding orthosis was medically indicated. Therefore, a custom cranial remolding orthotic was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue 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 pediatrics 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 Gazyva 1,000 mg intravenous infusion, every 15 days, for 2 doses.Medical literature does not support that the requested medication is medically necessary to treat the patients medical condition. At this time, Gazyva (obinutuzumab) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic lymphocytic leukemia and follicular lymphoma. Gazyva is not presently approved for minimal change disease (MCD) or nephrotic syndrome. Gazyva has not been shown to be effective in the adult population for the treatment of nephrotic syndrome. In this case, the patient has had a recurrence of MCD that was accompanied by acute kidney injury (AKI) and the need for dialysis therapy. At this time, the medical literature does not support the use of Gazyva to treat the patients medical condition. Accordingly, Gazyva 1,000 mg intravenous infusion every 15 days, for two (2) doses, is not medically necessary to treat the patients medical condition.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 subspecialty certification in nephrology, 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 the LINX Reflux Management System for treatment of his medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  However, the data to date on LINX is observational in nature and not generated from controlled, randomized trials.  Long-term efficacy and safety compared to other approaches such as traditional fundoplication or intensified medical therapy is not available.  Therefore, the requested LINX Reflux Management System is not likely to be of greater benefit than other treatment options. Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 enrollee is requesting authorization and coverage for individual psychotherapy services. The enrollee is requesting coverage for continued sessions with her current psychologist. The enrollees psychologist believes the enrollee should continue with her current therapist so as not to disrupt continuity of care. All individuals with alcohol use disorder should be encouraged to participate in some type of psychosocial treatment; commonly, some form of alcohol counseling and participation in a mutual help group.  Counseling in many substance use disorder treatment programs is based on the principles of 12-step programs, such as Alcoholics Anonymous. The sessions also focus on helping people avoid situations in which they are likely to encounter alcohol or drugs or triggers for their use, to plan safe social activities, and to continue attendance at mutual help groups between counseling sessions.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old male who presented to his pediatrician with a complaint of sore feet bilaterally almost one year ago. X-rays were taken and were negative for heal pathology. The patient was seen by an orthopedist who prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and apparently did not see a need to continue following the patient. In November 2005 the patient saw a podiatric specialist who noted pain and gait abnormality and diagnosed the patient with bilateral plantar fasciitis. The patient continued follow up visits with the podiatric specialist in December 2005, January 2006, April 2006 and May 2006. At this point in time, the patients podiatric provider has recommended endoscopic plantar fasciotomy (EPF) and has submitted a request for authorization of the procedure. The Health Plan denied the request citing a lack of medical necessity.During the past eight months the patient has been treated with NSAID therapy, ice therapy, stretching exercises, physical therapy, orthotics, strappings, and immobilization with a CAM walker. In May 2005 it was suggested that the patient undergo EPF due to the fact that he has been unresponsive to prior treatment modalities. The record reflects an appropriate course of conservative care for the treatment of the patients plantar fasciitis. His podiatric specialists recommendation for surgical intervention is reasonable and medically indicated at this juncture. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nucynta ER 100 mg twice daily for treatment of the enrollees fibromyalgia and myofascial pain syndrome. Findings:  The physician reviewer found that the Centers for Disease and Control and Prevention (CDC) indicate that epidemiologic studies suggest that concurrent use of benzodiazepines and opioids may put patients at greater risk for potentially fatal overdose. The CDC also indicates that clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. In this case, the patient is taking 7.5 morphine milligram equivalents (MME)/day. The provider proposes to increase this to 87.5 MME/day. There is no rationale provided for this considerable increase in the MME/day. Also, the record demonstrates that tolerance has taken place. In this clinical setting, adding more pure mu agonists for a short while will treat the symptoms of mu agonist saturation. However, down regulation will transpire and then the patient is back to where they started in terms of perception in pain. In addition, the patient will likely be worse off since the patient now has a much higher opioid tolerance level and it would take much longer to wean off the pure mu agonist with even greater pain in order to reset their mu agonist receptors. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for Xolair injections for treatment of her asthma. Findings:  The physician reviewer found that her nocturnal symptoms, she would be classified as having severe persistent asthma. She had nocturnal symptoms nightly and she received monthly steroid injections (which could be considered equivalent to oral), and discontinuation of steroids allowed progression of symptoms and decreased activity level. The requested medication is medically indicated for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for minimally invasive/percutaneous sacroiliac (SI) joint fusion surgery. Findings: The physician reviewers found that the authors of a clinical trial on minimally invasive SI joint fusion using triangular porous coated implants in patients with SI joint dysfunction, due to degenerative sacroiliitis and SI joint disruption reported improved pain, disability and quality of life at 24-months. The procedure was associated with a decrease in opioid usage for SI joint or low back pain. Current guidelines require documentation of significant SI joint pain or limitations in activities of daily living because of SI joint pain; at least three positive SI joint provocative tests; and confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period. In addition, the patient should fail to respond to at least six months of conservative therapy; and alternative diagnoses have been ruled out. This patient presents with a history of bilateral SI joint pain. Functional limitations are noted due to SI joint pain in activities of daily living and work ability. He experienced 100% pain relief following a SI joint injection during the anesthetic phase. Moreover, he has failed to achieve adequate relief comprehensive conservative treatment. Therefore, the requested minimally invasive/percutaneous SI joint fusion surgery is 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 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Dupixent pen auto injector 300 mg/2 mL. In a systemic literature review, Seger and colleagues concluded that for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. Paller and colleagues found that dupilumab and topical corticosteroids were effective and well tolerated in children aged 6-11 with severe atopic dermatitis, significantly improving symptoms and quality of life. In this case, the patient has tried and failed topical therapies and emollients. Given that current  medical literature reports that Dupixent is safe, well tolerated and effective in treating children with atopic dermatitis, the requested medication is medically indicated. Therefore, a Dupixent pen auto injector 300 mg/2 mL 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 33-year-old female enrollee has requested authorization and coverage for Caris Profile genetic testing. Findings:  Two out of three physician reviewers found that the current standard of care approaches for endometrial adenocarcinoma include surgery, radiation, cytotoxic chemotherapy and hormonal therapy. Biologic therapies have also shown some response rates. There are 2 phase II trials demonstrating the safety and efficacy of bevacizumab in endometrial cancer. Further, the National Cancer Institute (NIH) recommends clinical trials for such patients and considers such referrals standard care. The NCI is also enrolling into the MATCH trial where targeted therapies are given to those patients with amenable mutations. One study of 86 patients reported the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Given these findings, the Caris Profile genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   One reviewer found that the Caris Profile genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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 a laparoscopically assisted vaginal hysterectomy with salpingo-oophorectomy.Laparoscopic-assisted vaginal hysterectomy is considered definitive treatment for abnormal uterine bleeding and potentially may alleviate symptoms of pelvic pain. That said, hysterectomy is not the first-line treatment for these chief complaints in the setting of normal uterine pathology without an obvious source of pain. Typically, providers will consider performing a hysterectomy when there is a predominant uterine pain component by history and/or examination and the patient has exhausted a large number of other multimodal treatments. In this case, pelvic congestion syndrome is seen on imaging via ultrasound, however, it is not a definitive cause of her pain and hysterectomy is not the first-line treatment for it. The clinical documentation in this case is limited.  There is no description of her bleeding or her pain. The extent of these symptoms, the impact they have on her life, why she is choosing hysterectomy over a less invasive option is also not addressed. Additionally, a hysterectomy may not relieve her pain, may only partially relieve her pain, and, in some cases, can worsen pain or cause a new pain that she did not previously experience. Therefore, a laparoscopically assisted vaginal hysterectomy with salpingo-oophorectomy is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 61-year-old female enrollee has requested bilateral breast reduction for treatment of her macromastia. Findings:  The physician reviewer found that breast reduction surgery removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion to a patients body and to alleviate discomfort associated with overly large breasts. While the submitted photographs show a female with moderately large ptotic breasts, the patients condition is not considered an abnormal structure of the body. There is no evidence of breast asymmetry or disease or infection affecting the breast tissue. The patients breasts are not considered abnormal structures of her body. Therefore, the criteria of the California Reconstructive Surgery Statute are not met in this patients case and thus the requested procedure is not reconstructive in nature.With regard to the medical necessity of the proposed procedure, this patients complaints of back, shoulder and neck pain are consistent with her diagnosis of macromastia and the submitted photographic evidence confirms moderately large ptotic breasts. The planned surgical breast reduction of 300 grams per breast is relatively small, and is not likely to correct her symptoms. According to Schnur and colleagues, a reduction weight of 750 grams per breast would be required to meet the 22nd percentile. In that study, resection weights above the 22nd percentile indicated that a patients motivation is purely medical.  The planned resection of 300 grams for this patient is below the 5th percentile guideline of 479 grams. According to Schnur and colleagues, this would suggest that the procedure is for cosmetic purposes.