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

The representative of a 26-year-old male enrollee has requested residential treatment for treatment of the enrollees schizophrenia. Findings:  The physician reviewer found that although the RTC may have provided intensive and useful services, the records provided do not support a finding of medical necessity of this intensive level of care during the period at issue. It appears that the patient presented with symptoms of depression, anxiety and psychotic symptoms of his serious mental illness. However, the records do not indicate that he posed a risk of harm to him self or others. The patients Clozaril levels obtained were within therapeutic range (nor=29, cloz=473). Overall, the records do not support the need for 24-hour monitoring and care in a locked psychiatric facility as the patients symptoms were not described as severe enough to warrant constant supervision to intervene with his behavioral issues. For these reasons, the RTC services provided from during the period at issue have not been established as medically necessary and the denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for surgery services (CPT codes 57410 - manipulation procedures on the vagina, and 49320 - laparoscopic procedures on the abdomen, peritoneum, and omentum). Findings:  The physician reviewer found that many etiologies, including gynecologic and gastrointestinal pathologies, may cause pelvic pain in adolescents. Diseases typically associated with such pain, such as autoimmune causes, may be ruled out based on the patients history and physical examination. The diagnosis of endometriosis, which is associated with pain, may be challenging in adolescents, and treatment typically consists of nonsteroidal anti-inflammatory drugs (NSAIDs) and hormone therapy. Laparoscopy may be an option if pain persists following medical therapy, or if diagnostic testing is recommended prior to the initiation of hormone therapy due to age or side effects. In this case, the submitted records did not include sufficient documentation, including a well-documented history, physical examination, and medical workup, to fully assess the possible etiologies of this patients pain. Given the insufficient clinical documentation submitted for review, the requested services are not medically indicated at this time. Therefore, surgery services (CPT codes 57410 - manipulation procedures on the vagina, and 49320 - laparoscopic procedures on the abdomen, peritoneum, and omentum) are not medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee has requested participation in a clinical trial, Inamed Corporation Style 410 Silicone Filled Breast Implant Continued Access Reconstruction/Revision Expansion (CARE) Clinical Study for the treatment of the enrollee, who is status post bilateral mastectomy and reconstruction. Findings:  Two physician reviewers found that the provider notes asymmetry of the inframammary folds, lateral constriction and bending. These issues all point to capsular irregularities, not implant problems. A more projecting implant will not likely resolve these issues. This will involve removal of Alloderm remnants, reconstruction of inframammary folds, capsular excision and new implants. Potentially, the implants might need to be moved from retropectoral position to prepectoral, although their location is currently not clear. Current style implants are adequate. The medical literature does not demonstrate a more beneficial effect from the use of the requested implants over standard, currently available implants.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested computed tomography of the heart for evaluation of her risk for coronary artery disease.  Findings:  Two physician reviewers found that based on American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) guidelines, the presence of diabetes, the patients age and gender and lipid abnormalities being treated with a statin place her in a higher risk category for occult CAD. Especially given the patients history of diabetes, a single CT evaluation for risk stratification is recommended as a Class IIa indication based on the medical literature (Scholte, et al; Becker, et al). All told, the requested services will help determine whether any further non-invasive assessment or treatment is necessary to address the patients atypical symptoms.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested a motorized scooter for treatment of her degenerative joint disease and undifferentiated connective tissue disease. Findings:  The physician reviewer found that this patient does not meet generally accepted guidelines for medical necessity for a power mobility device. Inability to perform mobility-related activities of daily living without the use of a power scooter has not been documented. The question of whether the patient's impaired mobility could be adequately accommodated through alternative devices such as a cane, walker or manual wheelchair has also not been addressed. In addition, the ability of the patient to safely operate a power scooter or wheelchair and the capacity of her home to accommodate such a device has not been definitively established.  Finally, a formal assessment of the patient's seating system needs, critical to implementing a proper seating system that optimizes function, has not been performed.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for transporting the enrollee back to the United States.Findings: Air ambulance is considered medically necessary under certain circumstances. These circumstances can include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport. Another circumstance would be when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance. A patient might also require air ambulance services in order to be transferred from one institution to another in order to receive specialized services such as trauma care or a burn unit. Patient conditions to be considered include: unstable vital signs, spinal cord injury, severe chest or abdominal injury, severe burns, or amputations. In such cases, air transport is medically necessary in order to transfer the patient to the closest facility capable of providing a higher level of care. In this case, the patient was described as stable upon arrival to Torrance. The documentation noted that the patients chest tube had no air leak on arrival in Torrance. The tube was clamped. The pneumothorax had resolved. The chest tube was removed. His vital signs were normal. He did not require an acute surgical intervention. Further, TMMC is not a trauma center. The submitted documentation does not establish that the patient could not have been appropriately treated in Costa Rica. As such, the documentation provided does not support the medical necessity for air ambulance transport from San Jose, Costa Rica to Torrance, California. Therefore, air ambulance services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 emergency 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Relpax 20 mg for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that the patient has a history of chronic migraine and the standard treatment includes preventives such as amitriptyline, and abortives, such as triptans. The response to each triptan is patient specific, in terms of benefit and side effects. Parkinsons side effects are not typical with triptans. The records state that Parkinsons side effects were reported with a non-triptan medication containing isometheptene. Almotriptan is a reasonable abortive treatment for this patient. However, it unclear from the documentation provided that this was initiated with this patient. Only after a documented trial and failure with almotriptan, should Relpax be initiated. For these reasons, Relpax 20 mg is not medically necessary for treatment of this patient. 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 sub-specialty certification in 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: Overturned

A 22-year-old male enrollee has requested acute inpatient eating disorder services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, discharge on the date indicated would have been inconsistent with good medical practice.  The patient had a body mass index of 15.8 upon admission.  Per the medical records, he had only gained 3 ounces.  This calls into question the success of the critically important re-feeding stage.  He began treatment with a serotonergic enhancing medication upon admission and an antipsychotic medication was added due at least in part to persistent loose associations, thought blocking and tangential speech.  In addition to psychopharmacotherapy, the patient received comprehensive services including nutritional counseling, individual therapy, and occupational therapy.   However, the patient continued to have symptoms of cognitive disarray, anxiety and eating disordered schemas until his transition to the residential level of care.  In sum, the services were reasonably expected to improve his condition and prevent a more serious episode of illness.  All told, acute inpatient eating disorder services were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for AMONDYS 45 (casimersen), 30 mg/kg once weekly infusions. Findings:  The physician reviewer found that In a study of the safety and tolerability of casimersen in 12 patients with advanced Duchenne muscular dystrophy (DMD) who were nonambulatory or unable to tolerate a six minute walk test, Wagner and colleagues found no tolerability issues related to the medication. The U.S. Food and Drug Administration (FDA) approves the use of Amondys 45 based on an increase in dystrophin, a protein that helps keep muscle cells intact, production in skeletal muscle observed in patients treated with the therapy. It is indicated for the treatment of DMD in patients with a confirmed mutation of the DMD gene that is amenable to exon 45 skipping. Wilton-Clark and Yokota report that while no cure currently exists for DMD, casimersen targets exon 45 of the dystrophin gene and is expected to treat approximately eight percent of the DMD patient population. While there are no results from phase 3 trials available as clinical trials are ongoing, the medication has been FDA approved under its Accelerated Approval Program, which allows for the approval of drugs for serious conditions where there is an unmet medical need, and a drug is shown to have certain effects that are reasonably likely to predict a clinical benefit to patients. In the absence of other disease modifying therapies for this rare but ultimately fatal disease, the requested medication is more likely to beneficial than other available standard treatments in this clinical setting to preserve this patients motor and cardiac function. Therefore, AMONDYS 45 (casimersen), 30 mg/kg once weekly infusions, is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested AMONDYS 45 (casimersen), 30 mg/kg once weekly infusions, are 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 and 2 are board certified in neurology with sub-specialty certification in vascular neurology.  Physician reviewer 3 is board certified physical medicine and rehabilitation with sub-specialty certification in pain medicine 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: Overturned

The patient is a 68-year-old woman who has had an ulcer of her right lower extremity for approximately two years. It recently measured 2.2cm x 1.7cm. The ulcer was reportedly initiated by a thorn. Treatment has included Doryx, Biafine cream, silver nitrate and Dynacin, all of which have been ineffective. The patient reportedly is a diet controlled pre-diabetic. At issue is whether Regranex is medically necessary for treatment of her leg ulcer.Based on the submitted clinical information, it is medically necessary that this patient be treated with Regranex. The other standard therapies have been tried and failed. It is common medical practice to use Regranex in this clinical setting regardless of the patients diabetic status if other standard therapies have been ineffective. The success rate of Regranex is significant and the risk/benefit ratio is highly favorable. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. California Health and Safety Code 1345(h) states that Health Plans must cover urgent care services to prevent serious deterioration of a patients health resulting from unforeseen illness or injury for which treatment. This patients records document that he presented to a provider in Israel with complaints of unintentional weight loss, constipation, melena, and loss of appetite. The provider noted concern for colorectal cancer and recommended a colonoscopy to be performed as soon as possible. Current medical literature supports the use of fast-track colonoscopy for the evaluation of this patients change in bowel habits, gastrointestinal bleeding, and unintentional weight loss, all of which are concerning for colorectal cancer (Gregory). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines support the use of colonoscopy in this patients clinical setting as a delay in the diagnosis of colorectal cancer can be detrimental (Early, et al.; Lee, et al.). Given the patients drop in hemoglobin, an evaluation for possible sources of lower gastrointestinal bleeding was indicated (Strate and Gralnek). Given the patients presentation and history, the colonoscopy helped to prevent serious deterioration of the patients health resulting from unforeseen illness or injury. Accordingly, the colonoscopy was provided for the treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the services were for the treatment of an urgent medical condition as defined by California law. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for Zepatier 50 -100 mg for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  The guidelines state that patients with cirrhosis are high priority for treatment, and that cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks.  Both medications are U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage, and have proven highly effective. The guidelines recommend either Harvoni or Zepatier as acceptable therapy.  NS5A resistance testing is negative in this case, as recommended prior to Zepatier use in genotype 1a.  However, the guidelines do state that Harvoni should not be used in patients taking omeprazole at a dose of higher than 20 mg daily.  In this case, the patient reportedly cannot decrease the dose of omeprazole 20 mg twice daily, and decrease in omeprazole may result in vomiting that could cause pill loss and treatment interruption or failure.  For these reasons, Zepatier 50 - 100 mg is medically indicated 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing assay. In this case, the patients initial biopsy revealed a transection of the tumor as tumor infiltrating cells traveled down adnexa in the specimen and were possibly deeper than the initial biopsy. According to the National Comprehensive Cancer Network (NCCN) guidelines, this unusual clinical circumstance means that we cannot accurately fit this patients tumor into stage I or II. The value of accurate staging is to provide prognostic information in order to guide follow-up and treatment. In this patients case, the use of DecisionDx-Melanoma molecular genetic testing is likely to assist in guiding follow-up and further surveillance. If this patients tumor were to show results suggestive of a higher risk of metastasis, this would support closer surveillance and possible imaging. Since this is a unique clinical scenario without specific evidence-based guidelines, the DecisionDx testing for this patient was likely to be helpful to guide his follow-up care with his provider, and no other standard of care testing would have been able to provide these data. Given these findings, the DecisionDx-Melanoma genetic testing assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma genetic testing assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

A 69-year-old female enrollee requested joint manipulation under anesthesia (right forearm, wrist and fingers) for medical treatment of hers joint manipulation disorder. Findings:  Three physician reviewers found that the current peer-reviewed medical literature includes retrospective chart reviews, small sample sizes, and single case series. However, there are no controlled studies or any studies reporting long-term beneficial results. Given the lack of scientific data demonstrating that joint manipulation under anesthesia is likely to provide improved health benefits over treatment with standard available therapies, the services were not likely to have been more beneficial for treatment of the patients medical condition than any available standard modality.