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

The parent of a 13-year-old male enrollee has requested applied behavioral analysis (ABA) services and supervision for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient is a 13-year-old male with a diagnosis of autism and has been receiving ABA therapy for years. Based upon the documentation provided, there has been limited improvement in the patients behavior since ABA therapy was initiated. His progress report noted limited gains in cognition, language, adaptive and social skills during the specified time frame. Similar limited changes are noted when comparisons are drawn from the progress report which stated that aggressive outbursts were reduced while the patient was receiving ABA therapy. Thus, continuing ABA therapy is not likely to be an effective therapeutic approach for this patient. His present maladaptive behaviors include screaming, aggressiveness and combativeness which have resulted in psychiatric hospitalizations. ABA therapy has not been shown to be beneficial for patients such as this patient who present with significant maladaptive behaviors that have not responded to previous ABA therapy. Based on the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested a knee scooter for treatment of her right ankle bimalleolar fracture.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the device at issue. The documentation submitted for review indicates that the patient is status post two surgical interventions to the right ankle as a result of a fall. The patient was noted to be non weight-bearing, and had a prior history of a right shoulder injury due to a motor vehicle accident. Therefore, crutches would not be appropriate for this patient as utilization of crutches during the patients recovery from the right ankle injury would put undo strain on the patients right upper extremity. Therefore, considering the patients full clinical picture, utilization of a knee scooter from the time frame specified was medically necessary for the treatment of the patients right ankle bimalleolar fracture.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested Concerta (methylphenidate ER) 27 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that based on review of the available records, this patient is diagnosed with ADHD and has been treated for several years with Concerta, or its generic equivalent, for this disorder. Concerta has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD in this patients age group. In addition, the records document that this patient has been on this medication for a number of years with good results and without side effects. The provider and the patients parent also noted that these results have been with the generic form of this medication. Most patients do well with either methylphenidate drugs or amphetamine based drugs. This patient is doing well on a methylphenidate product, and the Health Plan has recommended three of four alternatives that are amphetamine-based products. Finally, the only methylphenidate product on the list is not the equivalent of Concerta. Concerta has a unique osmotic release oral system (OROS) based delivery system that improves absorption and bioavailability of the medication. All told, the requested Concerta (methylphenidate ER) 27 mg is supported as medically necessary for treatment of this patients ADHD.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the intensive outpatient program (IOP) services provided. Findings:  The physician reviewer found that this case incorporates all elements of the biopsychosocial-spiritual model of conceptualization and represents a patient burdened with prominent psychiatric impairment complicated by unresolved, longstanding psychodynamic conflicts. The co-occurrence of major depression and generalized anxiety are of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, that anxiety related mood disorders are difficult to treat. The records document that this patient presented with significant pain, mood symptoms, and anxiety following a suicide attempt one month earlier. The patient reported that she felt very fragile. The provider noted her glumness, depression and anxiety, and increased a medication to address the lingering depression and anxiety. The patient endorsed self-injurious impulses. Thereafter, she continued active treatment that was reasonably expected to consolidate treatment gains, further her clinical improvement and prevent a more serious episode of illness. Additionally, the IOP services facilitated a gradual and seamless transition to the outpatient setting and did not exceed duration consistent with typical community standards. In sum, the IOP services provided during the dates of service in question were appropriate and consistent with good medical practice and thus medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 53-year-old male enrollee has requested for intravenous gamma globulin therapy for treatment of his idiopathic polyneuropathy.  Findings:  Two physician reviewers found that as reported by Dyck and colleagues, IVIG has been shown to be effective in the treatment of chronic inflammatory demyelinating polyneuropathy. However this patient does not meet the clinical criteria for that diagnosis based on the guidelines provided by the American Academy of Neurology (AAN). In addition, there is a paucity of medical literature or supporting the use of IVIG for idiopathic neuropathy. Accordingly, the effectiveness and safety of IVIG for treatment of this patients idiopathic polyneuropathy remains investigational and unproven in the scientific data.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested monitored anesthesia during endoscopy for medical evaluation of her gastric mucosa-associated lymphoid tissue (MALT) lymphoma.  Findings:  The physician reviewer found that there are advantages with MAC versus benzodiazepines and narcotics for patients with risk factors for sedation-related complications and for patients undergoing prolonged procedures. Conscious sedation and MAC are often used interchangeably for those undergoing gastrointestinal procedures, however the most invasive and prolonged procedural settings, such as endoscopy with EUS with multiple biopsies warrant monitored anesthesia care. In sum, MAC was medically necessary for evaluation of the patients gastric MALT lymphoma.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old male enrollee requested the LINX Reflux Management System procedure for medical treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that the request for LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The gold standard in this clinical setting is Nissen fundoplication. In addition, there is a lack of controlled trials comparing the efficacy and safety of LINX to Nissen fundoplication. Additionally, anti-reflux surgery is designed to be effective long-term, longer than 10 years, which is seen with the standard operation of Nissen fundoplication. Moreover, the patient may suffer from problematic dysphagia after the procedure due to abnormalities with bolus clearance. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Three physician reviewers found that the patient has been diagnosed with refractory chronic migraine.  She has tried and failed standard preventives.  Large phase III studies of Botox for treatment of individuals with chronic migraine who are not on other preventives show definitive clinical and statistical benefit in reduction of headache days in comparison to placebo. A responder rate (at least a 50% improvement in headache days) of nearly 70% was seen in patients treated with Botox. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives (typically about 50%), suggesting that Botox may in fact be more effective than standard preventives, even in individuals who have not tried and failed standard therapies. Thus, there is adequate evidence that Botox is more beneficial than placebo and is clinically beneficial in the majority of patients.  In the phase III trials of Botox for chronic migraine, improvements were seen in a number of relevant parameters, including disability and quality of life.  As she has already failed standard preventives, and has reported benefit with Botox, the requested Botox injections are likely to be the most efficacious treatment alternative for this patient. I have determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for laboratory testing, chromosomal microarray analysis and fragile X analysis (CPT 81229 and 81243). Findings:  The physician reviewer found that Chromosomal microarray is considered first-line testing for non-syndromic developmental delay or intellectual disability, autism spectrum disorder, or multiple congenital abnormalities without a specifically well delineated genetic syndrome. Fragile X testing is indicated for patients with intellectual disabilities, developmental delay, or autistic spectrum disorder. In this case, the patient has a documented developmental verbal learning disability. Based on the symptoms described, he appears to meet the criteria for the diagnosis of autism spectrum disorder. However, the constellation of symptoms provided is not consistent with fragile X syndrome. All told, the laboratory testing, chromosomal microarray analysis and fragile X analysis (CPT 81229 and 81243) performed was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the testing at issue was 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 psychiatry with sub-specialty certification in addiction 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: The patient has requested reimbursement for inpatient hospitalization services. The California Department of Public Health (CDPH) requires three consecutive negative cultures, two weeks of therapy, and clinical improvement before allowing patients with tuberculosis out of isolation. In this case, while the patient was not acutely ill, he was found to have active tuberculosis and was being assessed for pulmonary lesions.  Although he was started on appropriate therapy, the patient continued to have positive sputa for tuberculosis. The patient underwent antituberculosis therapy and his first set of three negative cultures were obtained. The records stated that the county health department was required to clear this patient for discharge. This is relatively common practice as it is necessary to assure that the household has no children at high risk for acquiring tuberculosis, instruct the patient in how to take the drug therapy, and arrange follow up. Health department clearance was still pending until the end of the hospitalization. Given that this patient had active tuberculosis, required isolation, and required health department clearance prior to discharge, the services at issue were medically indicated. Therefore, inpatient hospitalization services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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 medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old transgender female enrollee has requested vaginoplasty for treatment of her gender identity disorder. Findings:  The physician reviewer found that in this case, the patient has been diagnosed with gender identity disorder and has been living as a female since the date indicated, which exceeds WPATH criteria by several months. The requirement that the patient live as the desired gender for a period of two years is not consistent with generally accepted standards in this setting.  All told, the patient is an appropriate candidate for vaginoplasty and meets medical necessity criteria for the procedure at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of excess skin and tissue beneath the thighs and buttocks. Findings:  The physician reviewer found that the medical documentation provided for review does not demonstrate that surgical treatment of the proposed areas meets medical necessity criteria. Although the submitted photographs show significant excess skin of the medial thighs and there is some suggestion of functional impairment, specific conservative management has not been adequately documented.  Further, the photographs provided show only mild excess skin of the buttocks. As such, the medical necessity of removal of excess skin and tissue beneath the thighs and buttocks has not been established.With regard to whether the requested services meet reconstructive surgery criteria, the patients excess skin following weight loss is considered an abnormal structure of the body caused by obesity, a disease. The proposed procedures would be to create a more normal appearance. The surgery is likely to provide more than a minimal improvement in the appearance of the patients medial thighs, but not for the buttocks. The patient has significant excess skin of the medial thighs and correction would provide more than a minimal improvement in appearance of the thighs. However, this is not the case for the buttocks. As such, correction to the buttocks would not provide more than a minimal improvement in appearance. Therefore, based on the documentation provided for review, the request for removal of excess skin and tissue beneath the thighs has been established as reconstructive in nature for treatment of the patients medical condition, but reconstructive in nature for the patients buttocks. Final Result: The reviewers determined that a portion of the requested surgery is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested computed tomography (CT) scan of the brain for evaluation of his medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patients history is not supportive of intracranial pathology presenting with loss of consciousness.  The medical record does not support the potential diagnosis of an unwitnessed seizure.  Neurocardiogenic syncope, cardiac pathology or possibly alcohol intoxication associated loss of consciousness are more likely diagnostic possibilities which would not require intracranial imaging.  All told, the requested CT scan of the brain is not medically necessary for the evaluation of this patient.   Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the enrollees medical condition.  Credentials/Qualifications: The reviewer is board certified 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his medical condition.  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 define acute hepatitis C as presenting within six months of the exposure with new rise in alanine aminotransferase (ALT) without alternative cause or low or fluctuating hepatitis C RNA values. In this clinical setting, the guidelines also state that the provider and patient may elect to treat or to delay treatment initiation. In this case, the patients provider has elected to initiate treatment with Harvoni for 12 weeks. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic Hepatitis C Genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of the patients hepatitis C infection. 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 authorization and coverage for Botox injections for treatment of the enrollees Parkinsons disease. Findings: All three physician reviewers found that Botox has been used for many years for focal dystonia, cervical dystonia, blepharospasm, and spasticity. In addition, Botox has been shown to be well tolerated, and highly effective in dystonia in patients with Parkinsons disease. In a recent study, they concluded that, Botox injection significantly improved foot dystonia, pain and lower limb functional outcomes in patients with Parkinsons disease with deep brain stimulation. 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld

This patient is a five-year-old female with difficulties with speech. The patient has been exposed to in utero drugs and has had recurrent middle ear infection requiring myringotomy tubes on three occasions, most recently at the beginning of 2005. The patient has received speech therapy through a regional center and the school system since 2002. A speech evaluation from the school system performed in May 2004 reported average expressive language skills and receptive language skills. However, the patient presented with a moderate phonological disorder. The patients provider performed a speech evaluation in March 2005, which supported the earlier conclusion of normal expressive and receptive language delays, but delays in the production of sounds.At issue is whether speech therapy is medically necessary for the patients condition.In reviewing the literature regarding intrauterine drug exposure and speech delays there are no reports of speech delay with heroine. Cocaine use causes both expressive and receptive language as well as global developmental delay. It is well documented by two therapists that this patients expressive and receptive language have normalized and only articulation errors remain so there does not appear to be a strong correlation between drug exposure and speech.Furthermore, review of the relevant literature regarding hearing loss and effusion reveals the outcomes are mixed regarding the use of tympanic membrane tubes. There is little data regarding speech therapy and intermittent hearing loss as documented in this case. A study by Paradise, et al. reports only approximately 35% of children with intermittent hearing loss below the age of three have speech delay. Expressive language is the most common problem with chronic hearing loss. Articulation errors as described by the patients therapist are educationally based deficiencies rather than medical issues. As such, standard of care is to manage the patients condition through other means than individual speech therapy. The primary need in this case is for the patient to practice articulation in real-life situations, in the home, school and the community. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.