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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Epclusa 400-100 mg one tablet daily for 12 weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested Epclusa 400-100 mg one tablet daily for 12 weeks is supported as medically necessary for the treatment of this 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: Medical Necessity
Decision: Overturned

The parents of a three-year-old male requested authorization and coverage of additional speech therapy for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested speech therapy is not medically necessary for treatment of the enrollees speech-language disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that additional speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa syringe 20 mg/2 mL (one injection to the right knee once per week for three weeks). Findings:  The physician reviewer found that there is good 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. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this case, this patient has bilateral knee arthrosis and standard treatment such as with pain medications or activity modification is not for symptoms in one knee only. The patients symptoms have been present for years and are now becoming intolerable. The patient has an ulcer and is no longer a candidate for nonsteroidal anti-inflammatory medications. All told, the requested Euflexxa syringe 20 mg/2 mL (one injection to the right knee once per week for three weeks) is medically necessary for this patients painful knee arthrosis.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage of Oasis, a special wound product for treatment of the enrollees post-surgical back wounds.  Findings: Two physician reviewers found that chronic wounds can remain unhealed after three or more months of treatment in 40-60% of patients. The molecular environment of chronic wounds exhibits numerous changes that impede healing. High levels of inflammatory cytokines are associated with chronic inflammation, and high levels of matrix metalloproteinases (MMPs) degrade extracellular matrix (ECM). Degradation of the ECM interferes with the dynamic and reciprocal cell-ECM interactions that are essential in every step of wound healing. Oasis is an intact matrix naturally derived from porcine small intestinal submucosa (SIS). SIS has been applied to chronic wounds in an attempt to address the ECM deficits and stimulate the cell-ECM interactions that are necessary for healing to occur. In randomized, controlled trials, SIS has been found to significantly increase the percentage of wounds healed and the healing rate compared to standard of care alone. As a naturally-occurring ECM, Oasis supports the adherence, proliferation, migration, and differentiation of numerous cell types. The bioactivity of Oasis includes releasing growth factors, minimizing the destructive activity of MMPs, and induces angiogenesis to support new blood vessels in growth. Oasis is biodegradable and can be well incorporated into tissue. Based on these considerations, treatment of this patient with the special wound product Oasis, was likely to be more beneficial than any available standard therapies for treatment of this patients chronic wounds.Final Result: Two reviewers determined that the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are 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 42-year-old female enrollee has requested for laboratory lipid studies for evaluation of her hypertension. Findings:  Three physician reviewers found thatthe patient had no significantly increased risk for coronary artery disease or cerebrovascular disease. She had mild hypertension, hypothyroidism and a mildly elevated lipid profile. Although her lipid profile was mildly elevated, there is no substantial evidence that lipid fractionalization testing is of more use in making treatment decisions or result in better outcomes than standard lipid profiles in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Motegrity 2 mg tablets. The records provided for review document that this patient presents with chronic constipation. The patients symptoms have failed to substantially improve despite treatment with osmotic and stimulant laxatives, as well as Amitiza. The patients provider has recommended treatment with Motegrity. Per the American Gastroenterological Association (AGA) guidelines, newer agents such as Motegrity should be considered for use in patients with constipation when non-pharmaceutical laxatives are ineffective (Bharucha, et al.). On review of current available published data on the treatment of chronic constipation, Hong reported that Motegrity is an effective and safe option based on all the studies currently conducted. In addition, Motegrity has been shown to be beneficial in the management of constipation and associated symptoms including bloating and abdominal pain (Tack, et al.; Jadav, et al.; Camilleri, et al.). For these reasons, the requested Motegrity 2 mg tablets are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for combination therapy with Botox and Aimovig. The enrollee has a history of migraines and was referred to a neurologist for evaluation of chronic migraines. She had been on several preventative medications and failed. She had been receiving botox injections to treat her migraines and headache frequency was decreased after the injections. However, she had not had injections for the previous six months and her headache frequency had increased again. The enrollee received a Botox injection and Aimovig with her first dose of Aimovig resulting in a reduction in headache frequency. She received another Botox injection during the visit and was advised to continue Aimovig. A subsequent visit indicated the current combination of Botox and Aimovig had resulted in diminished headaches, from nearly daily to only six to eight per month. In addition, they were less severe, of shorter duration, and responded better to Frova in that only one dose managed the headache and there was no rebound. To date, current research on Aimovig (Erenumab) is limited to monotherapy (use of a single drug), prophylactic (preventative) treatment for chronic migraine. When the use of Aimovig (Erenumab) was approved for chronic migraine prophylaxis, the decision was based on three trial studies that supported the efficacy and safety of the drug as a monotherapy, and not as a combination therapy with other prophylactic regimens, such as Botox. Rather, according to a research review of multiple studies conducted for Aimovig (Erenumab), these studies specifically excluded individuals who recently had a Botox injection, within four months of screening/baseline, from the study participation. Thus, while there is some literature speculation on the possible combined effect of Aimovig (Erenumab) and Botox on targeting and stabilizing the inflammatory marker that is elevated in enrollees with chronic migraine, there have been no actual studies conducted to support the efficacy and safety of this combination (Aimovig and Botox) therapy.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing (MTHFR) for the evaluation of his medical condition. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Studies have shown that clinically useful predictors are scarce for antidepressant therapy, and the results are inconsistent. They have shown that there is only marginal clinical association between enzyme system variants and selective serotonin reuptake inhibitor (SSRI) metabolism, efficacy, and tolerability in the treatment of depression. There is a lack of large randomized trials that have been conducted which would support the use of genetic testing in this case. The existing studies have indicated that there was no significant correlation between either genotypes or antidepressant serum concentration and response to antidepressant treatment. The current evidence does not support the use of genotyping when choosing an antidepressant.  Even less is understood about its utility in the treatment of anxiety disorders.  Genetic testing lacks evidence-based research to show its effective use in guiding the clinician towards choosing a medication regimen.  Therefore, the services at issue were not likely to have been more efficacious than other methods of evaluating this patient.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in psychiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female with chronic plantar fasciitis. She has requested authorization for extracorporeal shock wave therapy (ESWT). A review of the documentation provided indicates various treatments including night splints, orthotics, steroid injections, and physical therapy have failed. Therefore, the patients provider has requested authorization for ESWT.While review of the literature demonstrates there is some evidence ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed conservative therapy, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of ESWT or any adverse effects it may cause. In addition, there have been some conflicting results among the randomized, controlled studies thereby raising doubts regarding the efficacy of ESWT. A recent randomized, placebo-controlled, double-blind, clinical trial yielded results that contradicted the positive findings of previous studies. At this time, there is nothing to indicate that ESWT is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male is requesting for SPECT scan for the evaluation of his anxiety and depression. Findings:  Three physician reviewers found that SPECT is a neuroimaging technique that gives computer generated, 3D, in vivo images of the body using radiopharmaceuticals, gamma rays and a gamma camera. SPECT is used in the diagnosis and treatment of various medical conditions, such as cardiac studies that evaluate for myocardial infarction and ventricular arrhythmias. These particular studies concern perfusion and ischemia usually relating to stroke volume, ejection fraction, cardiac wall thickness and contractility.  Other common uses and accepted applications include bone scans and white blood cell scans to evaluate and treat lymphomas, tumors and other types of pathophysiologies involving white blood cells.  SPECT is used in brain scan imaging to assess glucose metabolism and brain damage from ischemic processes and to help evaluate dementia versus stroke. SPECT is not approved for use in the evaluation and/or treatment of anxiety and/or depression and there is no evidence to support its use for such evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential substance abuse treatment. The submitted documentation supports the medical necessity of the services at issue. In this case, the patients alcohol use was impairing her daily routine and contributing to significant impairment across multiple domains of functionality. Her drinking was straining her relationships. Her excessive consumption resulted in blackouts, falls, tremors and medical issues, such as transaminitis and hypertension. Further, she had co-occurring depressive illness and a history of benzodiazepine abuse. Finally, despite completion of an intensive outpatient treatment program during the episode of illness, the patient was unable to maintain sobriety in her environment. Based on the records, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services were reasonably expected to improve her condition and prevent a more serious episode of illness. In sum, residential substance abuse treatment was 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 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 45-year-old male enrollee requested cervical artificial disc surgery for treatment of his cervical degenerative disease, cervical radiculopathy and left-sided C5-6, C6-7 and central C6-7 herniated nucleus pulposus without myelopathy.  Findings:  Two physician reviewers found that Zechmeister and colleagues state, So far, cervical total disc replacement is not recommended for routine use. As many trials are ongoing, re-evaluation at a later date will be required. Future research needs to address the relative effectiveness between cervical total disc replacement and conservative treatment.  As there is a lack of high quality double-blind studies that compare long-term efficacy of cervical artificial disc replacement compared to standard treatment options, the procedure at issue was not likely to be more beneficial for the treatment of the patient's diagnosis than any available standard therapy at this time.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested emergency medical services for the dates of service in question (including the services rendered by San Diego Imaging Medical Group, Rady Childrens Hospital, and Sharp Coronado Hospital). Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department with a fever and headache. A chest x-ray and laboratory testing to rule out infectious etiology were performed. The chest x-ray was positive for an upper lobe infiltrate. Due to the patients symptoms, and a history of travel outside the country in the past year, there was concern for active pulmonary tuberculosis. This presents a threat to the patients and the publics health.  The patient was transferred to a facility capable of admitting him to an isolation room until active pulmonary tuberculosis could be ruled out. Once his PPD was negative, the patient was discharged. In this case, the patients symptoms were consistent with an emergency medical condition. Therefore, the patient received emergency medical services provided on the dates of service in question (including the services rendered by San Diego Imaging Medical Group, Rady Childrens Hospital, and Sharp Coronado Hospital). Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. 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: Urgent Care
Decision: Upheld

A female enrollee requested ambulance services on an emergent or urgent basis.  The physician reviewer found that the patients bleeding and cramping was not acute or sudden in onset. She had been evaluated for her symptoms six days before and was non-compliant with the prescribed medication. No interventions were required during transport. In addition, the patient refused a pelvic exam after she arrived in the emergency department. Thus, her symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place her health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Thus, the patients symptoms did not meet prudent layperson criteria for emergent care or urgently needed services.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services. The records document an inflamed epidermal cyst on the cheek. The patient sought treatment on two consecutive days. The medical records indicate that the patient had a dime-sized area of redness and inflammation on the cheek.  The submitted documentation indicates that the lesion was not painful. The patient was treated with cephalexin, an oral antibiotic. This patient did not have signs or symptoms which were life threatening, urgent, or emergent in nature. Based on the records, the services at issue were not emergent in nature. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.