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

A 64-year-old male enrollee requested authorization and coverage of a PET scan to determine whether the enrollee is continuing to improve or if additional therapy should be instituted for the treatment of metastatic lung cancer.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested facial feminization surgery (mandibular segmental osteotomy and genioplasty) for treatment of her gender identity disorder. The physician reviewer found that according to the World Professional Association for Transgender Health (WPATH) Standards of Care, While most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures (e.g., breast augmentation, facial feminization surgery) can be considered purely reconstructive. A study by Capitan and colleagues found that the modification and elimination of masculine facial features allows patients to adapt more easily to the workplace and social and family environments. Upon review of the submitted clinical documentation including photographic images, the patients lower jaw and chin are not overtly masculine and are within the range of normal for a female. The photographs document a normal mandible that does not show retrognathia or prognathia. The mandible has acceptable chin position and the mandible is not excessively wide. The mandible shape is considered within normal size for a female. The proposed surgery may change the mandible and lower facial shape but the changes are not specific for gender and are considered cosmetic in nature. As such, the requested services are not medically necessary for the treatment of gender dysphoria. With regard to the reconstructive surgery criteria, the patients current facial features do not represent an abnormal structure of the body. The patients lower jaw and chin are within the range of normal for a female. Therefore, the requested services are not considered reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or reconstructive in nature. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The 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 authorization and coverage for GeneSight Psychotropics. The submitted documentation fails to demonstrate the medical necessity of the requested services. Per the literature, there is a lack of evidence demonstrating improved health outcomes due to genetic testing. There is a paucity of head-to-head comparisons proving that genetic studies are of clinical benefit. There are some circumstances that genetic testing is done for safety reasons. This would be the case for a patient who is starting carbamazepine. The test would be for HLA-B*1502 allele to test for possible Stevens-Johnson syndrome and toxic epidermal necrolysis. The patient is not currently on carbamazepine, and the documentation did not report that this is a consideration. Therefore, GeneSight Psychotropics 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 patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent 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: Medical Necessity
Decision: Overturned

Standard Review The patient has requested authorization and coverage for Epclusa for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Nature of Statutory Criteria/Case Summary: According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin (Feld, et al; Foster, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested Epclusa 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 evaluation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Synvisc injections. The submitted documentation supports the medical necessity of the requested services. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. The evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. In this case, the patient has been diagnosed with moderate osteoarthritis of both knees. She has constant bilateral knee pain with difficulty with activities of daily living. Insufficient relief with corticosteroid injections is documented. Therefore, the requested bilateral Synvisc injections are medically necessary for treatment of the patients medical condition.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 a combination of Sovaldi and Daklinza for 12 weeks for the treatment of his hepatitis C.    Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  Per the guidelines, patients with prior liver transplant are highest priority for treatment of hepatitis C.  For treatment-experienced ribavirin-ineligible genotype 3 patients with liver transplant, the guidelines recommend daily Daklinza and Sovaldi for 24 weeks.  The requested treatment duration of 12 weeks is not consistent with the guidelines. As such, the requested treatment with Sovaldi and Daklinza for 12 weeks is not medically necessary. Final Result: The reviewer determined that the requested medications 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for anakinra (Kineret) 100 mg/0.67 mL subcutaneously daily for treatment of the enrollees autoinflammatory syndrome.  Findings:  The physician reviewer found that The request for anakinra (Kineret) 100 mg/0.67 mL subcutaneously daily is medically necessary for treatment of the patients medical condition. A review of the peer-reviewed literature supports the use of Kineret for the treatment of the autoinflammatory condition, Schnitzlers syndrome. Schnitzlers syndrome is a rare and under recognized disorder. The presence of the chronic urticarial lesions and the monoclonal IgM component, which define the syndrome, are virtually constant. Intermittent fever, joint symptoms, and the increase in acute-phase reactants are also very frequent. The clinical course of the disease is usually chronic, with no spontaneous remissions, and treatment is difficult and often ineffective. Recent reports have described a dramatic response of some of these disorders to Kineret. Chronic urticaria, unresponsive to antihistamines is characteristic of Schnitzlers syndrome. Kineret, an IL-1 receptor antagonist has been associated with an excellent outcome. Within 24 hours of commencing Kineret, patients have had almost complete resolution of symptoms, and has since been able to return to work full time. Discontinuation of Kineret for one day, was associated with a rapid disabling return of symptoms in patients. Patients with Schnitzler Syndrome were shown to have a complete response, both symptomatically, and with a reduction in inflammatory markers and white cell count, to anakinra. The reported universal response to Kineret suggests a key role of IL-1 in the pathophysiology. Given the nature of the patients medical condition and lack of symptom improvement with conventional therapy, treatment with Kineret 100 mg/0.67 mL subcutaneously daily has been established as medically necessary for treatment of the patients medical condition.  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 allergy and immunology 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 representatives of a 12-year-old female requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a tertiary level facility, a referral to a neurosurgeon and a second magnetic resonance imaging (MRI) of the brain. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of pineal gland cyst.  Findings: Based on the documentation provided, the requested services are not medically necessary for the evaluation and treatment of this patients medical condition. This patient has a 9 mm cyst of the pineal on an MRI scan. He has not had any significant neurologic symptoms nor has he had any objective neurologic findings on examination. There were no other abnormalities on his MRI scan: no mass effect, no hydrocephalus and no evidence of increased intracranial pressure. Two CT scans of the head were normal and did not identify a pineal cyst, which is a common finding since the cyst fluid is isodense with cerebrospinal fluid. An incidental pineal cyst was found on a brain MRI scan, which was not seen on two CT scan. The medical literature indicates that in patients who are asymptomatic, there is no need for a repeat MRI scan. In this patients case, the cysts have been followed and deemed to be benign and not noted to grow. A study does not recommend a follow up imaging nor do they recommend a follow up neurosurgery surveillance.  The medical literature notes that pineal cysts are common MRI findings and are especially noted in asymptomatic individuals. They have been deemed incidental since they have not been not found to have clinical significance nor increase in size. They have been seen on scans performed for other reasons.  The medical necessity for tertiary care referral has not been demonstrated since the record indicates there are qualified credentialed providers available. As such, the patient does not need to present to a higher level of care because the necessary level of care is available in his medical community.  With regards to the neurosurgeon referral, the literature also states that incidental pineal cysts, as noted in this patient, do not require further imaging or neurosurgical surveillance. In sum, a referral to a tertiary level facility, a referral to a neurosurgeon and MRI of the brain are not medically necessary for the evaluation and treatment of this patients medical condition.Final Result: The reviewer has determined that the requested services are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The reviewer is board certified in neurological 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: An enrollee has requested reimbursement for an acute hospital stay. The submitted documentation supports the medical necessity of the services at issue. The postoperative instructions for toe-touch weight bearing were appropriate and medically necessary for management of the tibial plateau fracture status post open reduction and internal fixation. This patient had difficulty with ambulation, and transfer to a skilled nursing facility was medically indicated. As such, she could not have been discharged home. Complications after tibial plateau fractures can result in poor outcomes. Postoperative protocol and rehabilitation was important in this patients case. She was unable to ambulate independently. Therefore, the acute hospital stay 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 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: Urgent Care
Decision: Upheld

The parent of a then 1-year-8-month old female enrollee has requested emergency services for treatment of the enrollee's medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients mothers circumstances would believe the patient was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients mother indicates the patient was coughing and having difficulty breathing. Records from the ER describe the patient as being playful with normal vital signs. With normal vital signs, no fever and activity within normal limits, this patients condition would not have lead a prudent layperson to believe the patient was experiencing symptoms that required immediate medical attention.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically the patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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: Physician reviewer number one is board certified in diagnostic radiology 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 diagnostic radiology 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 diagnostic radiology 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 53-year-old male with a history of neck and back pain progressively worsening over the past ten years. He has been evaluated for surgery on the cervical spine by both an orthopedic spinal surgeon and a neurosurgeon, and both have discussed the treatment alternatives with him. The patient has requested that his surgery be performed by the consulting neurosurgeon. The Health Plan denied his request based upon a determination that it is not medically necessary that a neurosurgeon perform the surgery. I would normally consider an orthopedic spine specialist and a neurosurgeon fairly equivalent when it comes to operating on the spine. In this case the surgery proposed by the orthopedic surgeon is very extensive with three-level anterior cervical discectomy and fusion and partial propectomies. I would recommend that the Health Plan ensure the orthopedic spinal surgeon has the requisite qualifications. Subject to such assurance, I have determined the requested service is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female has requested the medication Botox for treatment of myofascial pain syndrome and muscle spasm.  Findings:  Three physician reviewers found that Botox injections are not FDA approved for chronic muscle or myofascial pain.  Botox injections are not a generally accepted intervention for chronic muscle/myofascial pain as there is inadequate/insufficient evidence to support the use of Botox injections in the treatment of chronic myofascial muscle pain.