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

An enrollee has requested authorization and coverage for Harvoni 90-400mg tablet for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.  The provider documented that there were significant findings in the laboratory results and reviewed them with the enrollee. The enrollee is reported to have a history of chronic hepatitis C. The plan of care included an order to start Harvoni 90-400mg once daily for twelve 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 should be treated, except those with limited life expectancy due to nonliver-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. Findings: 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. Finding report that AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this enrollees 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 subspecialty 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 opioid pain management for treatment of the enrollees right trigeminal neuralgia and migraine. Findings:  The physician reviewer found that that opioid risk mitigation tools should be part of practice and when patient safety issues are identified, such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should not be continued. Opioids are generally not recommended as first-line therapy and when used providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing may be used as a tool to monitor for aberrant behavior or drug misuse and opioids should be tapered when patient safety risks are identified. Overall, peer-reviewed guidelines support use of opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Pain assessment should include current pain, the least reported pain over the period since last assessment, average pain, and intensity of pain after taking the opioid, as well as how long it takes for pain relief and how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. This patients medical records report chronic pain and document use of ongoing opioid risk mitigation tools that support compliance with medication regimen. Further, the records describe functional benefit from the use of opioids and failure of other conservative care. Congruent with current guidelines, the requested for opioid pain management services are supported as medically necessary for treatment of this 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested the medication Forteo for the treatment of her osteoporosis.  Findings:  The physician reviewer found that the medical records did not reveal a work-up for postmenopausal osteoporosis to account for bone loss.  As the DEXA scan is the only scan available, there is no evidence demonstrating if the patient has a low baseline bone mass or is actively losing bone. In addition there is no objective evaluation of the patients osteoporosis and no evidence of trials of other therapies for her condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old female enrollee has requested a comprehensive evaluation and participation in a one-week outpatient program (which includes but is not limited to allergens, skin testing, laboratory testing, oral food challenges and nutritional evaluation) for the treatment of the enrollees allergies. Findings:  The physician reviewer found that the parent and physician letters do not document the medical necessity of a full evaluation and food allergy testing performed at the requested facility. Records indicate the patient has not undergone adequate skin testing, which must be performed before food challenge testing.  The letter from the physician states that the mother was interested in food challenges to nuts and seeds, and the plan was to perform skin tests first. There is no record that this testing was performed. The submitted records do not document the presence of life-threatening anaphylaxis on any occasion, for which oral challenge testing in a carefully controlled setting may be considered warranted.  In addition, the records do not document that the patient could not receive oral challenge testing at the clinic where she was being followed for her diagnoses or another in-network provider. Food allergy challenge testing may be appropriate for this patient, but only after performing and reviewing skin test results as recommended by her physician. There is no medical necessity to seek an additional evaluation for food allergies and the patients additional diagnoses of inhalant allergy, asthma and eczema at the requested facility.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-month-old male enrollee has requested a cranial molding helmet for the treatment of the enrollees head asymmetry. Findings:  The physician reviewer found that cranial helmet therapy is indicated for infants with positional plagiocephaly who have failed conservative treatment with positioning and physical therapy. There is no indication that these modalities were utilized in this patient. It has been suggested the patient has asymmetric premature closure of the sutures or craniosynostosis. No imaging results have been provided confirming this assessment. In the neurologists notes he reported a little more flattening on the right side with a normal neurologic exam. However, there is no evidence the asymmetry has been quantified with anthropometric measurements. Thus, the medical necessity of cranial helmet therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested the WalkAide functional electrical stimulator for treatment of her multiple sclerosis. Findings:  Three physician reviewers found that this patient has multiple sclerosis with weakness of the left leg and associated foot drop.  She has tried an ankle foot orthosis, but this has not led to significant improvement in her gait.  She has tried the WalkAide functional electrical stimulator device and reports a significant improvement in gait, fatigue, and activities of daily living.  Since this patient has tried standard therapy with an ankle foot orthosis and physiotherapy, and the Walk-Aide functional electrical stimulator resulted in improvement in function, the requested device is likely to be more effective than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of a pneumatic vest. The Health Plan denied the request indicating that the requested equipment is not medically necessary for the treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. 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. All told, the requested bilateral Euflexxa injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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 authorization and coverage for suction lipectomy tuck procedure. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition and are not reconstructive in nature. Findings: There is a lack of support in the documentation provided for the medical necessity of the requested services in this clinical setting. The patient previously underwent abdominoplasty following significant weight loss as a result of bariatric surgery. Based on the clinical documentation, there is no evidence of a functional impairment associated with a minimal to mild lower abdominal protuberance and asymmetric appearing abdomen. The photographs support that there is evidence of a relatively normal appearance given her previous weight loss and surgery. There is insufficient documentation from the medical record to support that the patient has a significant functional impairment associated with her lower abdominal findings. Therefore, suction lipectomy tuck procedure is not medically necessary for the treatment of this patient. In this patients case, the documentation provided does not show a functional impairment.  As such, the mild lower abdominal protuberance and excess skin is not an abnormal structure of the body. Based on the documentation provided, the protuberance is slight and relatively normal given the patients body habitus, previous weight loss, and surgery. Her condition should be considered as part of a treatment for obesity, which is considered a disease. However, there is insufficient documentation that a functional impairment exists. Since the appearance is relatively normal, the requested surgical revision would not likely provide more than a minimal improvement in the patients appearance. Accordingly, suction lipectomy tuck procedure does not meet the criteria for reconstructive surgery. Final Result: The reviewer determined the requested services are not medically necessary for treatment of the patients medical condition and are not 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: Experimental/Investigational
Decision: Overturned

The parent of a seven-year-old female enrollee requested the Dexcom continuous glucose monitoring system (codes A9277, A9278 and A9276) for medical treatment of the enrollees type 1 diabetes.  Findings:  Two physician reviewers found that the requested device will allow the patients family to better predict blood glucose variation in relation to a specific foods, specific times of the day, and unplanned issues with stress and activity.  Thus, they would be able to better adjust insulin doses.  Therefore, the requested Dexcom continuous glucose monitoring system is likely to be more efficacious than other options for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech therapy services for the treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that this patient's deficits negatively impacted his ability to communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. It was therefore medically appropriate and necessary to provide speech and language therapy for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet 10/325 mg, 1 tablet, 4 times per day.The patient has been on chronic opioid therapy for the past 10 years, primarily due to chronic shoulder pain related to rotator cuff tears and shoulder joint arthritis. The patients previous treatments include medication management with a variety of drug classes as well as physical therapy. The submitted documentation indicates that the patient has demonstrated self-prescribing behavior with an inconsistent urine toxicology screen that was positive for non-prescribed benzodiazepines. Both the patients primary care and pain management providers expressed concerns regarding her inconsistent urine toxicology screen and the combination of unprescribed benzodiazepines and opioids. The patients primary care provider has attempted to modify the patients opioid therapy, as suggested by the current guidelines, and to refer the patient to pain management and physical therapy. Records reflect that the patients treating providers have managed the patients care in a manner that is consistent with current recommendations from the national guidelines regarding chronic opioid therapy for non-cancer pain. Under these circumstances, Percocet 10/325 mg, 1 tablet, 4 times per day, is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication dosage 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 anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested growth hormone therapy for treatment of his idiopathic short stature.  Findings:  The physician reviewer found that this patient is being followed by a pediatric endocrinologist.  Based upon the clinical information provided, he is destined to become a short adult without treatment. The patient qualifies for growth hormone therapy under the 2003 FDA guidelines for idiopathic short stature. Growth hormone therapy is clinically indicated for this patient and is likely to be beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mechanochemical ablation procedures for treatment of the enrollees varicose veins. Findings:  2/3 physician reviewer found that the submitted records fail to demonstrate the superior efficacy of the services at issue. There is no documentation of symptoms or recent response to conservative treatments.  There is no recent pulse examination documented. Additionally, there is no formal duplex report demonstrating the reflux status of the truncal veins. It is not clear why a single vein was treated one day and a different single vein treated the following day. In sum, mechanochemical ablation procedures performed were not likely to have been of greater benefit than other treatment alternatives. Final Result: 2/3 reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in vascular 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.Physician reviewer number two is board certified in vascular 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.Physician reviewer number three is board certified in vascular 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

A 63-year-old female has requested emergency services.  Findings:  The physician reviewer found that the patient  presented to the Emergency Department (ED) with complaints of itching all over for three weeks.  The patient was uncomfortable, but was in no acute distress.   Her vital signs were normal. She was triaged with an acuity level of 4. She was evaluated by the physician and treated with oral Benadryl.  Blood tests including electrolytes and liver functions tests were unremarkable. The itching was relieved and the patient was discharged to follow up with her family doctor.At issue in this case is whether a prudent layperson in the enrollees 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.The patient had the symptoms for three weeks prior to her visit to the emergency department.  She had not sought medical attention during that time.  The patients vital signs were normal.  She did not describe any difficulty breathing. She was described as uncomfortable, but in no acute distress. She was treated with oral medications with relief.  The patient was not experiencing an emergency medical condition, as her life was not in serious jeopardy and that there was no serious impairment to bodily functions or serious dysfunction to any bodily organ or part.  The denial should be upheld. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for a sleep study. The clinical documentation provided for review noted that the patient underwent a home sleep test. However, this type of testing is limited in utility to the evaluation of obstructive sleep apnea (OSA). In this case, there was no documentation of a thorough sleep evaluation nor is there documentation of any signs or symptoms of OSA. In the absence of any clinical signs and symptoms to suggest the presence of OSA, the performance of a home sleep study is not consistent with the generally accepted standards of practice. As no clinical signs or symptoms of OSA were reported to warrant a home sleep study, the sleep study provided in this case was not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the diagnostic procedure at issue was 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 neurology with sub-specialty certification in sleep 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.