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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting the medication, Dupixent. Findings: The physician reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The enrollee has a diagnosis of atopic dermatitis. He was seen in a dermatology office for eczema and dermatitis on his legs and upper body and Clobetasol cream was prescribed. Examination revealed atopic dermatitis with excoriated scaly plaques of the right arm, left supraclavicular, and right chest. Clobetasol with Cerave cream was continued and a prior authorization for Dupixent was requested. He was seen in follow up and atopic dermatitis on his full body with failed treatment with Doxycycline and Bactrim DS. Culture of the right leg showed heavy growth of Staphylococcus aureus with sensitivity to Bactrim and Augmentin. Resistance to most antibiotics, including Doxycycline, and allergy to Bactrim is noted. Examination revealed red, hot, excoriated scaly plaques of the right anterior tibia and scaly, red, plaque with satellite pustules of the upper lip. He was diagnosed with atopic dermatitis, cellulitis, and impetigo of the right tibia and Mupirocin was prescribed. Nystatin was prescribed for his lip.  Dupixent injections were prescribed. The enrollees advocate indicates he is not a candidate for traditional immune suppressing treatments, such as methotrexate or Acitretin because the risks outweigh the benefits. Review of the record fails to provide sufficient evidence demonstrating the need for Dupixent. There is no documentation of trial and failure of alternative therapies, such as a topical calcineurin inhibitor, systemic medications including methotrexate, cyclosporine, or azathioprine.  These medications have proven safety and efficacy in the treatment of atopic dermatitis. A history of impetiginization is not an absolute contraindication to any of these medications. This enrollee has no noted history of immunodeficiency, contraindications or allergies to any of these medications.  According to the medical literature, cyclosporine, methotrexate, mycophenolate mofetil, and azathioprine are used for cases with severe, difficult-to-manage symptoms. A trial of cyclosporine is commonly administered first; if that is not successful, then treatment with the others can be attempted.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for body contouring surgery.At issue is whether the requested body contouring surgery to treat the patients mental health or substance use disorder is medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The current medical evidence supports the requested services in this clinical setting. This patient has been diagnosed with gender dysphoria. Per the submitted documentation, the patient has been receiving hormone therapy. The patient reports significant anxiety, depression and distress due to their gender dysphoria. Coleman and colleagues listed body contouring procedures as treatments for gender dysphoria. The World Professional Association for Transgender Health (WPATH) position statement on the medical necessity of gender affirming treatments states, Non-genital surgical procedures are routinely performed.these surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. Body contouring surgery is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, the requested body contouring surgery is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee requested authorization and coverage of partial hospitalization services. The Health Plan denied the request indicating that the requested services are not medically necessary for the treatment of the enrollees depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A  female enrollee has requested authorization and coverage for Myobloc (Botox) injections for treatment of the enrollee who has a history of fibromyalgia, irritable bowel syndrome, piriformis syndrome, and ankylosing spondylitis. Findings:  The physician reviewer found that The documentation provided notes that the requested treatment option was to address the patients piriformis syndrome, a variant of myofascial pain syndrome. A small study by Fishman and colleagues compared Botox injections with corticosteroid and lidocaine injections for the treatment of piriformis syndrome and found a greater decrease in pain with Botox injections.  An open label comparator study by Yoon and colleagues noted that Botox appeared superior to dexamethasone with lidocaine by the visual analogue scale. Although the evidence supporting Botox in this clinical setting appears less robust than what may be desired, Myobloc (Botox) injections into the piriformis muscle appears to be superior to the conventional therapy with corticosteroids and lidocaine for the treatment of this patients medical condition. Final Result: Two of 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in rheumatology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in rheumatology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in rheumatology 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 42-year-old female enrollee has requested magnetic resonance imaging (MRI) defecography for evaluation of her medical condition.   Findings:  Three physician reviewers found that this patient has chronic pelvic pain and urinary complaints, and there is no indication that there is any rectal etiology for her issues. MRI defecography is a technique specifically utilized for evaluation of rectal and defecation issues (as noted in the references cited above), and has no role in this patients care or work-up.  The article by Touchais and colleagues states, Fluoroscopic defecography and MR defecography enable identification of rectocele, rectal prolapse, enterocele, sigmoidocele with high prevalence in female patients with obstructed constipation, fecal incontinence, and chronic pelvic pain. This patient does not have fecal incontinence or obstructed constipation as part of her symptomatology, and has already undergone fluoroscopic defecography. This routine x-ray defecogram revealed a rectocele during defecation, and not when straining. The rectocele also was not present at rest or while being examined under anesthesia and this rectal finding is thus unrelated to her symptoms. An MRI defecogram would not add clinically useful information to her evaluation, and is not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar Intracept system (CPT code 22899, HCPCS C9752 and HCPCS C9753). The Intracept intraosseous nerve ablation system is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain. There should be documentation of symptoms that have not responded to at least six months of conservative care, accompanied by either Type 1 or Type 2 Modic changes on a magnetic resonance imaging (MRI). There is a paucity of published clinical data to support the use of this treatment modality in this clinical setting. One trial involving 17 patients treated for refractory chronic low back pain demonstrated improved patient reported outcomes for one year after treatment. Another study is a multicenter randomized control trial involving 225 patients with refractory low back pain and Modic changes in the treated vertebral bodies. The authors reported significantly greater improvement in patient reported outcomes at three months compared to a group of patients treated with sham intervention. However, findings on the long-term safety and efficacy beyond three months is lacking. Clinical conclusions on this procedures safety and efficacy, should be confirmed by additional investigators, and require longer-term safety and efficacy data prior to accepting the Intracept procedure as standard of care. Therefore, the requested lumbar Intracept system (CPT code 22899, HCPCS C9752 and HCPCS C9753) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested lumbar Intracept system (CPT code 22899, HCPCS C9752 and HCPCS C9753) is not 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 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy services and social skills for treatment of the enrollees medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Group speech therapy services and social skills are indicated to address the social skills deficits with the patients peers. The patient presents with good expressive and receptive language skills. However, standardized tests do not pick up the problems with social communication that is seen in a child with autism spectrum disorder.  According to the American Academy of Pediatrics People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. However, traditional, low-intensity pull-out service delivery models often are ineffective, and speech-language pathologists are likely to be most effective when they train and work in close collaboration with teachers, support personnel, families, and the child's peers to promote functional communication in natural settings throughout the day. In this case, group speech therapy services and social skills are medically necessary for treatment of the patients social skills and functional conversation speech skills. For the reasons stated, group speech therapy services and social skills are medically necessary in this clinical setting. Final Result: The reviewer 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 pediatrics with sub-specialty certification in developmental and behavioral 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

The patient is a 62-year-old female with a history of COPD, degenerative joint disease, hepatitis, and cholecystectomy. She was admitted to the hospital on 2/22/05 with a LLL infiltrate. A sputum culture taken on 2/25/05 demonstrated staphylococcus epidermis sensitive to cefazolin, gentamicin, and vancomycin. Zyvox was started on 2/28/05. Authorization and coverage for Zyvox was denied and vancoymcin was started. The patient was to receive 1 gm of vancoymcin intravenously every 12 hours until 3/14/05. The patient received this therapy until 3/9/05 when IV access was lost. Zyvox was subsequently ordered. The Health Plan has denied reimbursement for Zyvox indicating the medication was not medically necessary for treatment of the patients pneumonia.The Health Plans denial should be upheld. The provided documentation does not demonstrate medical necessity for Zyvox. There is no evidence of any culture positive for VRE, VISA or MRSA. The sputum cultures were positive for coag-negative staph, which in this case was unlikely to be pathogenic. Furthermore, the patient was not formally evaluated by an infectious disease specialist. For these reasons, I have determined the requested medication was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old male with complaints of pelvic pain for over three years. He has requested coverage for out-of-plan treatment for his pelvic pain syndrome. It appears the patient has seen numerous urologists both in and out of plan and has received virtually all of the standard therapies including antibiotics, antispasmodics, alpha-blockers, and advice regarding diet and exercises. Appropriate x-rays were performed to rule out spine and joint problems. The patient sought consultation from an out-of-plan provider who prescribed external and internal myofascial release treatments. As part of his treatment with this provider, the patient participated in a six-day Pain Intensive Clinic, which was described as a new treatment protocol. The patient wishes to proceed with his treatments as directed by the out-of-the-plan provider. The Health Plan has denied coverage for these services citing a lack of medical necessity.Chronic prostatitis, chronic pelvic pain syndrome, prostadynia, and prostatosis are terms loosely applied to a variety of pelvic and genital pain symptoms. Standardization of terminology and exact clinical characteristics are not well defined. There is a confusing array of physical and psychological factors at work in producing these symptoms. This is not to discount the distress these patients are experiencing. After acute and chronic bacterial prostatitis with documented infection are excluded, the vast majority of these patients are treated and improved with a combination of empiric antibiotics, anti-inflammatories, alpha blockers, anticholinergics, sedatives, avoidance of irritants, physical therapy sitzbaths, and time. All of these therapies have been offered to the patient from in-plan providers.Myofascial release therapy has been used to treat a wide range of painful complaints in many areas of the body. Therefore, it is not unexpected that some practitioners have attempted to apply it to chronic pelvic pain syndromes. However, there is no commonly accepted body of literature or standard of practice in urology that recognizes chronically contracted pelvic floor muscles as a cause of pelvic pain or myofascial release therapy as scientifically validated treatment for male pelvic pain. Thus, there is insufficient evidence such therapy is medically warranted in this case.Based upon the information provided, the treatment services offered by the Health Plan are medically reasonable and appropriate. There was and is no clinical indication in this case for out-of-plan urological evaluation or out-of-plan physical therapy services including myofascial release therapy and prostatic massage. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old female with a history of fatigue, fibromyalgia, Fanconis syndrome and Bartters syndrome. The patient had a traumatic brain injury at the age of 35 when she fell off a horse. She was unconscious for four hours. In 2002 she was felt to have growth hormone deficiency resulting from her brain injury 24 years earlier. Her IGF-1 level in 2002 was 107 ng/ml. In July 2002 she had a peak response of 3.2 ng/ml during Arginine GH stimulation testing. She appears to have been treated with Genotropin since 2002. According to the notes of her treating physician, the patient had some improvement of her fatigue after beginning growth hormone therapy. The patient is also receiving estrogen and Prometrium. Her cortisol level was normal on two laboratory tests. There is no ACTH level, TSH level and free T4 level documented in the records provided, nor has imaging data of the patients brain been provided.At issue is whether growth hormone therapy is medically necessary for treatment of the patients condition.This is a 59-year-old female patient with a history of head trauma at the age of 35. Pituitary insufficiency has been documented after head trauma. Most deficiencies occur within the first to fifth year following the injury. Pituitary deficiencies after five years are rare. Furthermore, the patients IGF-1 level before treatment was normal at 107 ng/ml. Her Arginine stimulation test showed stimulation to 3.2 ng/ml. An Arginine stimulation test alone is not sufficient to document growth hormone deficiency. ITT and ARG-GHRH are the gold standards for determining if a patient is growth hormone deficient. Moreover, there is no documentation in this case of TSH, T4 and ACTH levels and no imaging studies are documented. For these reasons, I have determined the requested therapy 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: The parent of a six-month-old enrollee has requested Nutramigen with Enflora LGG formula for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation supports the requested formula in this clinical setting. There are a variety of clinical syndromes and manifestations that would justify use of alternative formulas.  Syndromes such as enterocolitis, proctocolitis, and enteropathy, as well as severe atopic dermatitis, are all significant manifestations of cows milk protein allergy early in infancy.  The presentation may include vomiting, bloody diarrhea, abdominal distention, anemia, failure to thrive, eczema, and malabsorption.  Since cows milk sensitivity may be associated with sensitivity to soy, soy-based formulas are not indicated.  The literature supports the use of amino acid-derived formulas in severe cases. Casein hydrolysate formulas such as Nutramigen are medically indicated for cows milk protein allergy.  In sum, the requested Nutramigen with Enflora LGG formula is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested formula 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 pediatrics with sub-specialty certification in pediatric critical care 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.