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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that this patient presents with psoriasis affecting the scalp and intertriginous areas including gluteal cleft. He has tried and failed therapy with topical clobetasol. However, there is no documentation in the medical records of a failure of treatment trial or intolerance to any systemic agents including methotrexate, acitretin, or cyclosporine. Moreover, he has not tried and failed therapy with one of the Health Plans preferred injectable biologic agents. The medical records fail to demonstrate a reason for not using one of the formulary preferred agents. Thus, the requested Otezla is not supported as medically necessary for treatment of this patients plaque psoriasis. Final Result: The reviewer determined that the requested medication is 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 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.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date 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. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with abdominal pain. Although his abdominal pain was not acute in onset, he also reported numerous episodes of vomiting and diarrhea for the past three to four days. His vital signs showed a borderline tachycardia, prompting laboratory testing which revealed a mild acidosis, consistent with his clinical symptoms. The patients EKG was also abnormal, prompting cardiac biomarker testing to rule out acute coronary syndrome, which may also present as epigastric pain with nausea and vomiting. Based on the clinical documentation submitted for review, the patient received emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient received emergency medical services on the date 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: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. As per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Therefore, the patient should be approved for Harvoni for 12 weeks to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease. Final Result: Two reviewers 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology and is 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa knee injection services for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested services in this clinical setting. Evidence-based, peer-reviewed 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 allow for delay of total knee replacement, and is more effective than corticosteroid injections. In this case, the patient has been diagnosed with moderate to severe osteoarthritis of the right knee. She underwent prior Euflexxa injections, which reportedly worked well for months. She presents with recurrent right knee pain with difficulty in weight-bearing. Repeat injections have been requested in an attempt to delay total knee replacement due to her young age. Inadequate symptoms relief has been reported with corticosteroid injection. The current medical evidence supports the requested services in this patients case. Therefore, the requested Euflexxa knee injection services are 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 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

The guardian of a 15-year-old male enrollee has requested for Genotropin growth hormone therapy for treatment of the enrollees stated Prader-Willi syndrome. Findings:  The physician reviewer found that a methylation genetics test for Prader-Willi syndrome should be performed in order to verify the diagnosis. In the absence of such evidence, the case for growth hormone therapy is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

A 33-year-old female enrollee has requested intravenous immunoglobulin (IVIG) treatments for treatment of her myasthenia gravis.  Findings:  Two physician reviewers found that the use of IVIG has been established in the medical literature as a treatment for myasthenia gravis. According to the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) recommendations, the use of IVIG for MG is indicated if a patient has clinical worsening, is being started on corticosteroid treatment, is in preparation for a surgery, or requires a steroid-sparing agent. Achiron and colleagues also noted that in cases of severe generalized MG not responsive to other immunosuppressive drugs, the use of IVIG as a maintenance therapy has been shown to be beneficial. In this particular case, the patient needed this therapy in preparation for her surgery in order to minimize possible respiratory risks associated with MG. In addition, she also required this therapy as a steroid-sparing agent given the severe side effects documented with prednisone. Although this emergent IVIG course was indicated on the dates at issue, it is not supported as a long-term (greater than 9 months) medication for this patient in the absence of a trial of a more studied and proven immunosuppressant agent.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vosevi 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage. The guidelines recommend that cirrhotic or non-cirrhotic genotype 1a patients who have failed an NS5A inhibitor should be treated with regimens including Vosevi and Mavyret. The formulary alternative Mavyret is recommended as a treatment option in the AASLD/IDSA guidelines for retreatment of genotype 1 chronic hepatitis C after failure of NS5A inhibitors. These guideline recommendations are based on the MAGELLAN-1 clinical trial results showing a 94% cure rate in with Mavyret.  There is a lack of peer-reviewed published literature in the form of head-to-head clinical trials to establish that Vosevi is superior to Mavyret for retreatment of chronic hepatitis C, genotype 1 after failure of NS5A inhibitors. For these reasons, treatment with Vosevi 400-100 mg for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is 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: Upheld

A 31-year-old male has requested lumbar spine surgery at this time rather than two months from now for treatment of his low back pain.  Findings:  The physician reviewer found that fusion may be of value in the treatment of back pain resulting from an unstable or hypermobile segment or when there is mechanical instability or malalignment.  It is rarely indicated for routine discectomy or abnormal radiographic findings without appropriate clinical findings.  With an established indication, improvement can be expected.  The role of smoking in the incidence of postoperative complications has been reported.  In this patients case, there is documentation of the presence of an abnormality of the bony alignment in the lumbosacral articulation.  Although the patient has expressed a desire for the services of an out-of-network provider, the in-network provider has apparently expressed his willingness to undertake the procedure if the patient would cease smoking prior to the procedure.  In this patients case, the timing of the procedure is elective, as the medical records do not indicate an acute situation requiring lumbar spine surgery at this time.  All told, the requested lumbar spine surgery at this time rather than two months from now is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) lung biopsy and (2) thyroid biopsy. Haugen and colleagues note that thyroid nodules are a common clinical problem. The authors note that the guiding clinical strategy acknowledges that most thyroid nodules are low risk, and in general only nodules larger than one centimeter should be evaluated. Biopsies are invasive procedures that carry the risk of adverse outcomes for the patient. In this case, the documentation reflects stable and unchanged pulmonary nodules, and small thyroid nodules. The patients condition is being monitored and managed by repeat imaging in one- to two-year intervals. Given that the provider is following standard of care for management of the patients condition, the requested services are not medically indicated. Therefore, a (1) lung biopsy and (2) thyroid biopsy are not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services 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 certifications in pulmonary disease and 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.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested Orecea for treatment of her rosacea. Findings:  The physician reviewer found that although doxycycline is not available in a topical form and therefore is not a treatment alternative for rosacea, it is reasonable to treat this patient with oral doxycycline for at least one month prior to authorizing the requested Oracea. The approved indications and usage guidelines for the use of Oracea in the treatment of rosacea specifically state that Oracea may be approved for the treatment of inflammatory lesions of rosacea in adult patients that have demonstrated failure of, or clinically significant adverse effects to, doxycycline 50mg. Similarly, the study conducted by Del Rosso and colleagues concluded that doxycycline 40mg once daily (Oracea) has been shown to produce clinically significant improvement in patients with rosacea. However, the Toossi and colleagues study reported improvement in rosacea patients when treated with subantimicrobial doses of oral generic doxycycline 20mg twice daily. Therefore, it is clinically reasonable to treat this patient with generic doxycycline for at least one month, and if she demonstrates failure to this therapy, then authorize the requested use of Oracea.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee has requested for the Paradigm Real-Time continuous glucose machine and sensors for treatment of her diabetes mellitus. Findings:  Two physician reviewers found that continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypoglycemia and hyperglycemia in insulin-treated patients who are not in good control. Recent reports of monitoring up to three to six months in adults have shown improvement in A1cs and decrease in hyperglycemic and hypoglycemic episodes. There is sufficient evidence of the efficacy of the Paradigm Real-Time continuous glucose monitor to support the use of this device in this setting.
Appeal type: Urgent Care
Decision: Overturned

A 62-year-old male enrollee has requested reimbursement for emergency services.  Findings:  The physician reviewer found that the patient has a past history of prostatic hypertrophy who presented to the emergency department (ED) complaining of constipation, abdominal pain, nausea, nocturnal chills, subjective fever, and malaise for three weeks.  His vital signs and physical examination were unremarkable. An abdominal x-ray revealed marked bowel dilation. A computed tomography (CT) of the abdomen and lab work was normal. He was diagnosed with constipation and fever and was discharged home.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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.A prudent layperson would reasonably be expected to seek immediate medical attention due to symptoms of fever, chills, nausea, and abdominal pain which are persistent and not relieved after taking over the counter medications at home. Such presenting signs and symptoms may be suggestive of acute intestinal obstruction, appendicitis, colon cancer, abdominal aortic aneurysm and other conditions which could place the patients health in serious jeopardy. As such, these symptoms were indicative of a possible emergency medical condition and immediate medical evaluation was appropriate and indicated.  Therefore, the patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a nine-year-old male enrollee requested predictive genetic testing for non-malignant diseases, for medical evaluation of the enrollees obesity and impaired fasting glucose. Findings:  Three physician reviewers found that although testing for MODY does not need to be routinely performed on most children with diabetes mellitus, the recommended genetic testing was appropriate to help guide the patients lifestyle choices and medical treatment given his history and presentation. Thus, the predictive genetic testing for non-malignant diseases was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested foot orthotics for treatment of the enrollees foot pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested foot orthotics. Custom foot orthotics are the standard of care for treatment of patients with over pronation, subtalar joint valgus, posterior tibial tendinopathy, hallux limitus, and heel pain. Custom foot orthotics are utilized to correct pathologic biomechanics of the foot, and in the case of this patient will correct his subtalar joint valgus, loss of medial column upon stance and reduce the dorsiflexion of the first metatarsal. In addition, custom foot orthotics have previously helped this patient and his current orthotics have lost their effectiveness to support his feet. Based on the patients right foot and ankle pain due to significant abnormal foot biomechanics, painful posterior tibial tendinopathy at insertion with pain upon palpation to the medial foot, abnormal and painful gait, loss of medial arch upon ambulation with severe over pronation, the requested equipment has been established as medically necessary.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 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: Upheld

A 42-year-old female enrollee has requested for a total abdominal hysterectomy for treatment of her chronic pelvic pain and menorrhagia. Findings:  The physician reviewer found that There is no evidence that there was any evaluation of this issue (for example, hormone testing including thyroid function testing), nor any attempt to manage her menstrual complaints with hormonal methods, or oral contraceptives if she were to quit smoking. A hysteroscopy and/or dilation and curettage might have helped her bleeding complaints.  It also appears that the plan is to remove her ovaries with the hysterectomy, and there is no medical indication to remove the ovaries in this 42-year-old woman. There was no ovarian pathology on the ultrasound, and removal of the ovaries would induce surgical menopause and potentially create additional problems.