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

A 50-year-old male enrollee has requested  for gastric bypass surgery for treatment of his morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 39.7 and severe co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the 10% preoperative weight loss, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. Delaying surgery until the patient loses 27 ponds is not consistent with national criteria. According to the 2004 ASBS Consensus Conference, bariatric surgery candidates should not be required to have completed formal non-operative obesity therapy as a pre-condition for the operation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers 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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions.  Patients without cirrhosis who have hepatitis C, genotype 1 infection are recommended to be treated with Harvoni.  Additionally, treatment of patients before they progress to cirrhosis is advantageous.  Based on evidence of safety and efficacy in the published literature, Harvoni for eight weeks is medically indicated for the treatment of this patient. Final Result: Three 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: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

A 29-year-old female enrollee has requested duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 45.8 and several co-morbid conditions, which makes her an appropriate candidate for surgical intervention. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Furthermore, there is a body of scientific evidence that shows superior short and long-term outcomes with the duodenal switch procedure when compared to the gastric bypass or the lap-band procedure. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. As with any weight loss surgical procedure, the patient should undergo appropriate psychological evaluation prior to surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage for vitamin B12 injections. The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees pernicious anemia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested B12 injections are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma test. In reviewing the NCCN guidelines, the recommended therapy for patients with stage I cutaneous melanoma includes review of history, physical examination, and imaging to evaluate certain signs and symptoms. The NCCN indicates that category 1A treatment includes wide excision of the melanoma and consideration of sentinel lymph node biopsy. Furthermore, the NCCN guidelines state that for stage IB melanoma, the probability of a positive sentinel lymph node is greater than 10%. The NCCN guidelines do not endorse use of a gene expression assay to determine the course of treatment for patients with stage I melanoma. Marchetti and colleagues concluded that the prognostic ability of gene expression profiling tests among patients with localized melanoma have been found to be poor at correctly identifying recurrence in patients with stage I disease, suggesting limited potential for clinical utility in these patients. Given these findings, the DecisionDx-Melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent Syringe 300 mg/2 mL. The initial treatment of atopic dermatitis involves the use of nonpharmacologic interventions such as emollients, which is followed by use of topical corticosteroids or calcineurin inhibitors, like Elidel or Protopic. According to the American Academy of Dermatology (AAD) guidelines for the treatment of atopic dermatitis, topical calcineurin inhibitors like Elidel and Protopic are recommended for this patient given his failure to improve despite treatment with Claritin, fluocinonide, hydrocortisone, oral prednisone, triamcinolone, and Eucrisa. This patients records do not include documentation of failure or contraindication to treatment with standard first-line treatments to support an indication for treatment with Dupixent, which is a systemic medication. Dupixent is reserved for patients who fail nonpharmacologic interventions and first-line topical therapy. For these reasons, the requested Dupixent Syringe 300 mg/2 mL is not medically necessary for treatment of this patient. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks for treatment of the enrollees 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.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks.  These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  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: Physician reviewer number one 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: A female enrollee has requested authorization and coverage for Mavyret for eight weeks. 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. Moreover, the guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment her major depressive disorder. Findings:  Three physician reviewers found that transcranial magnetic stimulation (TMS) was first introduced as a novel method of non-invasive stimulation of the brain. TMS was approved by the Food and Drug Administration for the treatment of major depressive disorder in 2008. However, the peer-reviewed literature consists of varying reports on the efficacy, especially long-term, the potential side effect profile along with case selection, and the benefit of repetitive TMS therapy. Although the available studies in the peer-reviewed medical literature indicate that TMS is efficacious in the short-term treatment of depression, further studies are required to examine the long-term efficacy of this treatment for depression. As such, there is inadequate evidence that TMS therapy was or is likely to result in a superior clinical outcome for this patient compared to standard therapeutic alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injections in the knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of moderate relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Synvisc One injections in the knees 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

A 43-year-old female enrollee requested authorization and coverage of revision gastric bypass. 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 upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee is requesting Harvoni for the treatment of his hepatitis C infection. Findings:  The physician reviewer found that according to the 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 or viral load. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is 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 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor.  Harvoni is U.S. Food and Drug Administration (FDA) indicated for the treatment of chronic hepatitis C (CHC) genotype 1 infection in adults. In addition, Harvoni carries the highest American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommendation for treatment of HCV patients with this patients characteristics (AASLD/IDSA guidelines).  Research shows that once-daily ledipasvir-sofosbuvir with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. For patients such as this patient with viral loads less than 6 million IU/mL, Harvoni for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. The patients records do not support advanced fibrosis; however, the medical appropriateness of HCV treatment, as per AASLD/IDSA recommendations, exists regardless of fibrosis score. Specifically, the AASLD/IDSA guidelines support treatment in all HCV infected persons, except those with limited life expectancy of less than 12 months. For these reasons, the requested Harvoni is medically necessary for treatment of the patients HCV.  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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical conditionFindings:  Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue were 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 diagnostic radiology 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that Per Health and Safety Code section 1317.1,(a)(1) Emergency services and care means 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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. (b) Emergency medical condition means 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 joint. The records indicate the enrollee presented to an urgent care clinic with complaints of strong back pain after falling in her bathtub on a previous date. The enrollees blood pressure was 131/85, with pulse 94 beats per minute. Physical examination revealed normal gait with no tenderness or effusion. Her muscle strength and tone were normal.  Her spine was non-tender and there was no deformity, ecchymosis or rash noted. However, the enrollee had lumbar spasms with pain level of 7 out of 10.   Her diagnoses were lower back contusion and lumbar spasm.  Treatment was with baclofen and ketorolac.  In this case, the enrollee presented to the urgent care clinic with severe lumbar spine pain rated at 7 out of 10.  She appropriately received emergency medical services where she underwent a medical screening, examination and evaluation by an appropriate licensed physician to determine if an emergency medical condition existed. Although the enrollee had fallen previously, she had evidence of acute symptoms of sufficient severity (severe pain), such that the absence of immediate medical attention could reasonably be expected to place her health in serious jeopardy or result in serious impairment to her bodily functions. She received care and medication for her lumbar spasms within the scope of the physicians license to relieve the severe back pain, which was within the capability of the urgent care facility. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees expressive speech delay. Findings:  The physician reviewer found that consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy intervention is medically necessary in the treatment of this patients medical condition and should therefore be approved.