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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old male enrollee has requested CPT codes 64555, 64555-51 x 2, 77003-26, 95972 and 99144 for occipital and peripheral nerve stimulator trial for treatment of his pain. Findings:  Two physician reviewers found that the patient has received treatment with multiple modalities including suboccipital decompression. He has tried several medications and failed to achieve good results. Interventional blocks have been minimally and temporarily helpful, and his practitioner has noted that he would be a good candidate for peripheral and occipital nerve stimulation for the trigeminal and atypical facial pain and occipital neuralgia. These services have been shown to be effective in several case series.  Studies by Slavin, et al. and Jasper, et al. showed nerve stimulation had pronounced effect for individuals with severe headaches who have failed more traditional modalities.  These studies are small but show consistent efficacy. The patient at this point has limited treatment options. Other potential modalities include deep brain stimulation for the trigeminal or radiofrequency ablation of the Gasserian ganglion, but these are much more invasive and involve greater risk. In this patients case, given his young age, lack of significant viable alternatives and failure of so many conservative therapies, the requested services are medically appropriate. Although further study of nerve stimulation is needed to determine its long-term efficacy, new and emerging literature shows good results in selected, carefully screened patients who fail other more traditional approaches. As such, the requested occipital and peripheral nerve stimulator trial is likely to result in a better clinical outcome than the alternative treatments that remain for this patient
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anterior optical coherence tomography (OCT) (CPT 92132) provided by UCLA Jules Stein Eye Institute. Hwang and colleagues note that spectral-domain (SD) optical coherence tomography (OCT) may be used to distinguish patients with asymmetric keratoconus (AKC). While anterior OCT imaging is not necessary for routine use before penetrating keratoplasty, deep anterior lamellar keratoplasty (DALK), Descemet membrane endothelial keratoplasty (DMEK), or Descemet stripping automated endothelial keratoplasty (DSAEK) surgery, in this clinical setting, anterior OCT to image the cornea to determine the fitness of one of the available surgical options for keratoconus would be useful. OCT imaging of the posterior cornea is superior to the other option for evaluating the corneal fitness for keratoplasty, slit-lamp examination and specular microscopy, for discovering breaks in the Decemet membrane, especially when there is corneal scarring or a poor direct view of the posterior cornea.  In this clinical setting, the anterior OCT (CPT 92132) provided by UCLA Jules Stein Eye Institute was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the anterior optical coherence tomography (OCT) (CPT 92132) provided by UCLA Jules Stein Eye Institute at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 ophthalmology 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: Upheld

A female enrollee requested water assisted lymph node saving liposuction for medical treatment of her bilateral lymphedema. Findings:  The physician reviewer found that although the patient has undergone some traditional conservative management of her lower extremity enlargement, she does not appear to have undergone significant weight loss to possibly improve her condition and lessen any possible risk for surgical intervention. This patient should consider further weight loss to help treat her condition and to possibly become a better surgical candidate prior to consideration for surgical intervention. Thus, the requested water assisted lymph node saving liposuction is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female has requested coverage for brand name Prevacid for treatment of her stated condition of gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that based on review of the available records, there is no clinical evidence that this patient suffers from an acid related disorder as there is inadequate documentation of gastroesophageal reflux disease (GERD) endoscopically or by esophageal pH study. In addition, there is no evidence to support an advantage of one PPI over another for a likely case of functional dyspepsia. In summary, the requested medication has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old male with a body mass index (BMI) of 52. He is requesting authorization for a Lap-Band procedure. He reports a number of comorbid conditions including sleep disturbances, breathing difficulty, joint pain and abdominal discomfort. At issue is whether the Lap-Band procedure is medically necessary for treatment of the patients condition.Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. The patient can be appropriately treated with standard bariatric surgery procedures. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dental surgery and anesthesia procedure for treatment of the enrollees dental caries and chronic periodontitis. Findings: The physician reviewer found that Patients with special needs often present a challenge for the dental care team. The exacting and surgical nature of dental procedures requires significant patient cooperation to ensure the safe delivery of care. Some individuals who have special care needs have difficulty cooperating during treatment, thus creating a potentially harmful situation. The medical literature demonstrates that the safety of the patient and treating staff may be compromised when treating a patient with disabilities due to the patients inability to cooperate. In this case, the records demonstrate that the patient has a history of developmental delays and autism and is unable to sit in a dentist chair due to her disabilities. Final Result: The reviewers 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 dentistry 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 48-year-old female enrollee has requested Taxotere (docetaxel) and irinotecan for the treatment of her pancreatic cancer. Findings:  Two physician reviewers found that there is no clear-cut choice for second-line chemotherapy in the treatment of metastatic pancreatic cancer. All such treatments must be considered investigational due to a lack of controlled data indicating a clear impact on survival. However, there have been at least two recent reports suggesting some real clinical benefit with the combination of irinotecan with Taxotere. These studies coupled with the patients clinical response, suggest irinotecan with Taxotere is the most advantageous treatment option at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested  periodic pediatric neurology visits for treatment of the enrollees multiple medical conditions. Findings:  The physician reviewer found that the patient has an extremely complex multi-diagnosed history with diagnoses including autism, bipolar disorder, attention deficit hyperactivity disorder (ADHD), and Tourettes syndrome (TS).  Some of these drugs can cause significant side effects, including the exacerbation of the motor tics of TS, which is generally treated by a pediatric neurologist as it is a neurological motor movement disorder. Additionally, ADHD is frequently treated by a pediatric neurologist, often with psychostimulant medications which also can exacerbate tics. As noted in the article the multiple comorbidities of TS require very sophisticated medication management by a pediatric neurologist (Debes and colleagues).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy (CPT code 15830) and abdominoplasty (CPT code 15847). According to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. This patients records document that the panniculus hangs below the level of the pubis. The patient complains of a recurrent rash underneath her abdominal pannus and reports that she has used two antifungal medications in the past. However, there is no report that the patient has failed adequate and supervised medical treatment of the rash. The patient does not have a functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. Based on the evidence-based literature, the requested panniculectomy (CPT code 15830) is not medically necessary for treatment of this patient. According to the ASPS, abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. When indicated, the ASPS specified that CPT 15847 for abdominoplasty describes a cosmetic procedure. Thus, the requested abdominoplasty (CPT code 15847) is not medically necessary for treatment of 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; (2) to create a normal appearance, to the extent possible. In this patients case, an abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The patients abdominal pannus is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating hepatitis C virus recommend a daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for 12 weeks for treatment-naive patients with hepatitis C virus genotype 1 infection. The AASLD/IDSA recommendation is not to deny patients treatment if they have early stage disease, but to treat patients with HCV to avoid untoward complications from advanced disease. For the reasons provided, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients HCV.   Final Result: Two reviewers 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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 parent of a 14-year-old male enrollee has requested for growth hormone (GH) therapy (Nutropin AQ) for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that this patient has markedly delayed puberty; it appears his predicted adult height will be in normal range. If there is objective evidence of his low growth rate (1.2 cm per year), he would be an appropriate candidate for GH therapy. However in this case, no longitudinal growth records have been provided to substantiate that the patient has had falling growth rates. If longitudinal data is submitted (such as a plotted growth chart) demonstrating a low rate of growth, GH therapy would be medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested hyperbaric oxygen pressurization for the treatment of his necrotizing fasciitis. Findings:  Two physician reviewers found that HBO therapy in a monoplace or multiplace chamber is an accepted treatment in this setting. Topical HBO is investigational, but this is not the program that was recommended for this patient. The proposed therapy has established efficacy and is likely to benefit the patient as he has a Wagners 4 ulcer which has failed to respond to conservative care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female with long-standing opioid dependence, sedative-hypnotic abuse, and alcohol dependence in remission, generalized anxiety disorder, and depression NOS vs. major depression. She was admitted to an intensive outpatient program through her Health Plan on 4/5/04. She continued in this program until approximately 5/26/04, having become largely abstinent of substance abuse during this time. She was later admitted to inpatient care for detoxification on 6/7/04, after having taken 36 Morphine pills on 6/3/04, noting a prior overdose six weeks prior wherein she was hospitalized for five days. She was subsequently detoxified with Suboxone, tolerating the downward taper as well, last dose administered on 6/21/04. After this time, she was transitioned to seeing a psychiatrist, who she saw from 6/22/04 to 12/3/04. She has now requested authorization for individual therapy or residential treatment. She does not have coverage for residential treatment, although the Health Plan provided her recommendations on how to find such through the County. Throughout this time period the patient was treated with a number of psychotropics, ranging from Serzone, Prozac, Paxil, Risperdal, Seroquel, Depakote, Lithium, naltrexone, and eventually Celexa. January 2005 notes from the patients psychiatrist indicate the patient was struggling with depression and anxiety, interspersed with substance relapse, either in the vein of benzodiazepines, muscle relaxants, or opiates.The Health Plan reported the psychiatrist as not recommending individual therapy until the patient was consistently clean and sober, and had referred her to dual diagnosis groups, given the severity of her co-occurring psychiatric diagnoses. Cognitive behavioral therapy has also been offered via group psychoeducational classes as well as evening CBT groups. However, the patient declined returning to the chemical dependency recovery program.There appears to be nothing in the documentation provided to show the patient has not and was not provided appropriate standard of care for her various disorders. Accordingly, it is within the purview of her psychiatrist to recommend a prioritization of what would or would not benefit her. Asking that she be consistently abstinent from drugs and alcohol prior to beginning individual therapy, for example, is very much within the standard of care. Moreover, the Health Plan has offered the patient a number of treatment options for her various illnesses that are known to be appropriate and effective for treatment of the patients diagnoses. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent Syringe 200 mg/1.14 ml. AD is an itchy inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and their families (Paton). Treatment of AD usually starts with corticosteroids as well as phototherapy. Protopic ointment and pimecrolimus cream have also been shown be safe and effective in the treatment of patients with AD. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate to severe AD. Vangipuram and Tyring reported on clinical studies demonstrating that Dupixent substantially reduced the clinical manifestations of moderate to severe AD. The records provided for review document this patients AD has been resistant to systemic antihistamines, corticosteroids, and immunosuppressant medications. Given these findings, the requested Dupixent syringe 200 mg/1.14 ml is medically necessary for 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.