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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Orthovisc injection series for treatment of the enrollees degenerative osteoarthritis. Findings:  The physician reviewer found that Intra-articular injection of hyaluronic acid is an established part of treatment algorithms for management of osteoarthritic knee pain and is generally considered a second-line therapy after treatment with nonsteroidal anti-inflammatory medications. Multiple studies have documented the efficacy of intra-articular hyaluronic acid injections for osteoarthritic knee pain. All told, the requested bilateral Orthovisc injection series is medically necessary for this patient with documented osteoarthrosis which persists despite treatment with oral and topical nonsteroidal anti-inflammatory medications. 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 orthopedic 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 reimbursement and prospective authorization and coverage for skilled nursing facility care for treatment of the enrollees medical condition status post hip implant replacement.  Findings:  The physician reviewer found that the request for skilled nursing facility care provided were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is status post right hip removal of the prosthesis. The patient does not have a hip joint. The patient has made slow progress in physical therapy and further functional improvement with inpatient therapies is not likely. Skilled rehabilitation services are not clinically indicated for this patient. Further care can be provided in a custodial level setting. Thus, the documentation does not support continued skilled nursing level of care. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 12-year-old male who has been diagnosed with short stature. According to the provided growth charts, the patient has been growing close to the 20th percentile since the age of four years old. On 10/1/18, his bone age was 11 years old at a chronological age of 11 years and three months. On 12/20/18, the records noted the patients mothers height was 52 and the patients fathers height was 511. On 2/1/19, the patient underwent a growth hormone (GH) stimulation test with clonidine and L-dopa, which he failed. On 2/22/19, the patients height was 55 inches. On 4/19/19, the patients height was 55 and 3/8 inches. There was no documentation provided of the patients testicular volume. On 3/15/19, magnetic resonance imaging (MRI) of the brain was normal. On 6/18/19, the provider noted the patient was started on GH therapy in April 2019. The patients parent has requested authorization and coverage for a Nutropin AQ Nuspin Pen Injector 20 mg/2 mL. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a Nutropin AQ Nuspin Pen Injector 20 mg/2 mL is medically necessary for the treatment of the patients medical condition. Wilson and colleagues reported that considerable variability exists in the diagnosis of GH deficiency, which remains a clinical challenge. The physician reviewer found that related to the continuum between severe GH deficiency and normality, marked variability in GH assays, arbitrary cutoffs conventionally used to define GH deficiency on the basis of GH stimulation tests, and the lack of reproducibility of GH stimulation tests. Grimberg and colleagues reported a limit of 10 ng/mL in GH stimulation testing only predicts GH deficiency 25% of the time. In this case, the patients estimated predicted adult height is 58. This is a normal adult height for his genetic potential and is also normal adult height for a male. Based on the growth chart provided, there is no evidence of growth failure, and the patient has been growing consistently around the 20th percentile. The failed GH stimulation test in the absence of growth failure does not establish the diagnosis of GH deficiency. The medical evidence does not support the requested medication in this clinical setting.  Therefore, Nutropin AQ Nuspin Pen Injector 20 mg/2 mL is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male who has been receiving human growth hormone (HGH) treatment for almost one year for chest pain, neuropathy, and several other non-specific issues. The patient reports that his condition continues to deteriorate. He has requested authorization for continued growth hormone injections. The Health Plan has denied the patients request indicating that the submitted medical documentation provides no evidence of GHD or panhypopituitarism.The Health Plans denial should be upheld. There is no evidence in the submitted documented evidence of HGH deficiency. In fact, the patients continued reported deterioration is indicative of the lack of efficacy of the HGH therapy he has already received. Continued treatment with HGH therapy is not medically indicated and is not likely to be effective. 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections in both knees for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that As evidenced by this patients history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Colleagues reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors noted that that the current highest level of evidence suggests that viscosupplementation is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intraarticular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Overall, there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. In light of the foregoing, the requested hyaluronic acid injections are supported as medically necessary for treatment for management of the patients osteoarthritis of the knees. 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 orthopedic 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: A patient has requested authorization and coverage for weekly individual therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the requested services. Researchers state that psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression, or for patients with adherence problems. Overall, psychotherapy has been shown to be effective for acute depression, particularly in combination with antidepressants, and it can help in preventing depressive relapse and recurrence. The medical guidelines for the treatment of patients with major depressive disorder notes that depression-focused phototherapy is recommended to prevent a relapse of depression in the continuation phase. Researchers meta-analysis provides evidence that individuals with chronic, complex mental illness seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions is associated with better outcomes. In this case, psychotherapy has been shown to help reduce this patients symptoms and the patient requires maintenance psychotherapy for the management and treatment of major depressive disorder. The standard of maintenance psychotherapy is weekly, which is both appropriate to treat this patients condition, consistent with good medical practice and medically necessary. Therefore, weekly individual therapy is medically necessary for the treatment of this patient.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 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: Overturned

A 42-year-old female enrollee requested Enlite 530G insulin pump (E0784), sensors (A9276 x 90), and transmitter (A9277) for medical treatment of her type 1diabetes.  Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available options. In this case, the patient has low blood sugar levels in the 50s-60s range. The use of the Enlite system with the threshold suspend feature is likely to be beneficial for this patient and will likely lower the frequency of severe low blood sugars (Bergenstal, et al). Therefore, the requested Enlite 530G insulin pump (E0784), sensors (A9276 x 90), and transmitter (A9277) are likely to be more beneficial than other available therapies for this patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services provided in the urgent care setting. Per Health and Safety Code section 1345(h), Health Plans must cover urgent care services to prevent serious deterioration of a patients health resulting from unforeseen illness or injury. The records provided for review document that this patient presented for routine care in anticipation of moving abroad for the next two years. Services performed included an annual physical examination, pelvic examination, and colposcopy to address abnormal results from her pelvic examination. Researchers noted that, Patients with an abnormal cervical cancer screening history require surveillance, which differs from routine screening for patients with normal prior screening results. However, none of the services provided were provided for the evaluation or treatment of an unforeseen illness or injury. An annual physical examination, venereal disease testing, and gynecologic care could all have been safely scheduled on an outpatient basis. All told, the services were not urgent care services as defined by California law.  Final Result: The reviewer determined that the services at issue were not urgent care services as defined by California law. 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: Experimental/Investigational
Decision: Upheld

A female has requested authorization and coverage for enoxaparin (Lovenox) injections. The Health Plan has denied the requested medication as experimental for treatment of the enrollees infertility.Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists (ACOG) practice bulletin indicates that testing for inherited thrombophilias in patients who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin prevents recurrence in these patients. In addition, there is insufficient evidence of an association and, therefore, insufficient evidence to either screen for or treat women with inherited thrombophilia and obstetric histories that include complications such as fetal growth restriction or preeclampsia. The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first-degree relative with a history of high-risk thrombophilia. No such history is presented in this case. Therefore, the requested enoxaparin (Lovenox) injections are 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 medication is 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 obstetrics and gynecology 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:  An enrollee has requested gabapentin for treatment of her medical condition. Findings:  The physician reviewer found that the request for gabapentin is medically necessary for treatment of the patients medical condition. According to researchers, gabapentin is a first-line agent for neuropathic pain. The documentation submitted for review indicates that the patient has a condition of fibromyalgia syndrome for which she is being prescribed gabapentin. The condition of fibromyalgia syndrome is supported for the treatment with gabapentin. As such, gabapentin is supported as medically necessary for the treatment of fibromyalgia syndrome.   Final Result: The reviewer determined that the requested medication dosage 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 neurology and pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for custom orthotics. Biomechanical changes of a foot that cause abnormal motion and pain should be corrected. In this case, the patient presented with chronic bilateral arch pain. His diagnoses included plantar fasciitis, posterior tibial insufficiency, and hallux limitus. An examination showed over pronation with hypermobility of the first metatarsal, and posterior tibial insufficiency that placed undue and increased pressure to the posterior tibial tendon and on the plantar fascia, biomechanical abnormalities that can cause significant pain. In this clinical setting, given that custom functional firm orthotics may be used to keep the patients foot in neutral position, reducing not only first metatarsal elevation but also abnormal pull and strain on the posterior tibial tendon, the requested equipment is medically indicated. Therefore, custom orthotics are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatry 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

The patient has chronic daily headache, which has been responsive to daily triptans over the past two years. The submitted information indicates the patient has had success with a variety of triptans and generally uses one-half of a full dose. She currently is on Zomig 5mg and uses one-half tablet daily. She has previously failed Neurontin, Topamax, Depakote, NSAID, and Zonegran. A request has been made for 18 Zomig tablets per month. The Health Plan has denied the request.Analysis and Findings:While daily low-dose triptans are not standard of care, they are prescribed by headache experts around the world for patients who have failed standard treatment. This regimen is quite effective in a select group of patients. Additionally, daily triptan use does not appear to raise any safety concerns when prescribed for healthy patients. Thus, it is medically reasonable to treat chronic daily headache with 2.5 mg of Zomig daily. Therefore, I have determined that 16 tablets of Zomig 5mg per month are medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be partially overturned. Furthermore, due to the possibility of rebound headache, a seven-day discontinuance of triptan may be indicated to see if the patients headaches improve.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier test. Findings:  Three physician reviewers found that there is sufficient support for the Afirma gene classifier testing performed in this clinical setting. The patients biopsy revealed atypia of undetermined significance, and genetic testing showed benign results. The Afirma test was a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. Therefore, the Afirma GEC test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in intenal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A male enrollee requested Harvoni 90mg-400mg (12 weeks) for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that per American Association of the Study of Liver Diseases and the Infectious Diseases Society of America, immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority.  This patient meets classification as high priority for medically necessary treatment.  Therefore, Harvoni 90mg-400mg (12 weeks) is medically indicated for the treatment of this patient.