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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks for 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.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, Sovaldi and Daklinza for 12 weeks is first-line therapy in treatment-naive genotype 3 patients.  This patient is interferon-ineligible due to psoriasis, which can be exacerbated by interferon.  All told, the requested Sovaldi and Daklinza for 12 weeks are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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

The parent of a 17-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees pervasive developmental disorder.  Findings:  The physician reviewer found that typically, the medical communitys customary prescription for an autistic child would be ABA therapy. The medical literature strongly supports the treatment of autism with ABA therapy in children. However, this patient does not readily nor traditionally diagnose as autistic. The patient has moderate intellectual disability with a full-scale IQ of 58. A diagnosis of pervasive developmental delay is usually reserved for severely to profoundly intellectually disabled patients with some autistic features that cannot be clearly called autistic. In this patients case he has made significant progress, now functioning in a special day 10th grade class and demonstrating some academic skills. The patients major functional deficit is socialization with same age peers and poor pragmatic (social) language. Based upon the documentation provided, the patients presentation does not appear consistent with high functioning autism or PDD-NOS. In light of this fact, coupled with the patients relatively high level of function with significant progress functioning in a special day class as well as demonstrated academic skills, ABA therapy is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested monitored anesthesia care (MAC) services for the lumbar epidural injection for treatment of his degenerative disc disease.  Findings:  The physician reviewer found that based on the current medical literature and guidelines from the American Society of Anesthesiologists (ASA), the routine use of MAC services for most pain procedures is not supported. In addition, this patients provider did not document any condition that would require the use of MAC services during an epidural steroid injection. Therefore, the requested MAC services for the lumbar epidural steroid injection are not medically necessary for the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization, and storage of oocytes and/or embryos) who has been diagnosed with acute myeloid leukemia. Findings:  The physician reviewer found that egg retrieval and freezing (cryopreservation) is now a recognized option for women who have cancer and who are undergoing treatment that can render them infertile in the future by being toxic to their ovaries/eggs. This option allows these patients to have children in the future.  Technically, they are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of the chemotherapy. This procedure is a treatment that is appropriate to discuss and offer to such patients. As noted by researchers, prior to initiating potentially gonadotoxic therapy, physicians should discuss the risk of treatment-induced infertility and possible interventions to preserve fertility. Whenever possible, all patients with newly diagnosed cancer should meet with a reproductive endocrine and infertility specialist if fertility is a concern, preferably before treatment. This treatment is supported by the American Society of Reproductive Medicine. For patients such as this, when chemotherapy is anticipated to damage or destroy the eggs, such a treatment is medically necessary. The American College of Obstetricians and Gynecologists also supports this treatment, noting oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. Other researchers noted that discussion of fertility preservation and appropriate referral for treatment of reproductive age (and younger) cancer patients should be a routine part of cancer care, noting that sperm and embryo cryopreservation and oocyte cryopreservation are considered standard practice. 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 obstetrics and gynecology 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 40-year-old female enrollee has requested for inpatient detoxification for treatment of her Soma dependence. Findings:  The physician reviewer found that an attempted inpatient detoxification via Emergency Room intake, the patient decided to leave and have further discussion with her outpatient provider.  Intensive outpatient program services have been recommended to manage this patients anxiety, and these recommendations were not followed.  At this time, inpatient detoxification is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Rezum transurethral destruction of prostate tissue (CPT/HCPCS codes 53854, 96372, and J1885). This patient presented with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. He has failed conservative treatment with medical BPH management. He underwent further work-up, which revealed a prostate size less than 80 grams and presence of a median lobe. BPH is non-cancerous enlargement of the prostate which often causes urinary obstruction leading to lower urinary tract symptoms of weak stream, frequency and nocturia. Treatment begins with medical management including alpha blockers, 5-alpha reductase inhibitors, or a phosphodiesterase inhibitor. Patients with significant frequency and urgency may also be treated with antimuscarinics like oxybutynin or the beta-3 agonist Myrbetriq. When patients fail, or do not tolerate medical management, they frequently proceed to surgical treatments to improve their urinary symptoms. Surgical treatments for BPH include transurethral resection of the prostate, which has been associated with significant side effects. In an effort to reduce patient morbidity, more minimally invasive techniques are being developed. The minimally invasive Rezum system utilizes convective radiofrequency water vapor thermal therapy. The U.S. Food and Drug Administration (FDA) approved the Rezum device in 2015. The advantage of the Rezum system is the use of convective heat energy rather than tissue ablation. A prospective, blinded, randomized controlled trial demonstrated improvements in urinary quality of life scores and urinary flow rates that were durable through three years of follow-up with minimal adverse outcomes (Gupta, et al.). In addition, the use of Rezum for the treatment of refractory urinary symptoms from BPH is supported as a treatment option in the most recent American Urological Association (AUA) treatment guidelines, including the 2019 and 2020 updates, and is now considered standard practice within the urologic community (Foster, et al.; Parsons, et al.). Given this support, the Rezum transurethral destruction of prostate tissue (CPT/HCPCS codes 53854, 96372, and J1885) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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: Medical Necessity
Decision: Upheld

The patient is a 54-year-old female with hypercholesterolemia and a family history of coronary disease. She has been experiencing symptoms of chest discomfort and pressure with heavy exertion and with rest. The patient has a left bundle branch block on ECG. She underwent an exercise stress echo, which did not demonstrate ischemia. An exercise stress nuclear study was abnormal. The nuclear test demonstrated evidence for a prior nontransmural infarct in the distribution of the left anterior descending with residual ischemia. The patient has requested an additional non-invasive electron beam computed tomography (EBCT) scan as an alternative to coronary angiography to confirm or exclude the presence or absence of significant coronary artery disease.EBCT is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. In addition, EBCT is not an accepted substitute for coronary angiography and would not be able to confirm or exclude important coronary obstruction. The use of EBCT in the diagnosis and prognosis of coronary disease currently remains an unproven application of this technology. Therefore, I have determined that the requested EBCT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent enrollee has requested authorization and coverage for sinus surgery. Pediatric rhinosinusitis is a common sequela of upper respiratory infections in children. It is usually a self-limited disease, sometimes requiring antibiotic therapy. Chronic rhinosinusitis (CRS) in children is difficult to treat, with resultant frequent recurrences and failures. The available medical treatments include antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions. Adenoidectomy is among the most frequent surgical procedures performed on children, but randomized studies have failed to prove that adenoidectomy alone is sufficient to manage CRS. Instead, functional endoscopic sinus surgery is a minimally invasive technique which restores the sinus ostia patency and can re-establish ventilation and drainage through the natural pathways. Surgery may be indicated in children with complications of acute rhinosinusitis, severe recurrent acute rhinosinusitis, rhinosinusitis in cystic fibrosis with or without polyposis, chronic rhinosinusitis refractory to maximal medical management, allergic fungal sinusitis, and paranasal sinus mucoceles. In this patient with CRS who is status post adenoidectomy and has been treated with maximum medical therapy, sinus surgery is supported as medically necessary. 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 otolaryngology 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 patient has requested authorization and coverage for Zepatier. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 1a patients should be treated with Zepatier when nonstructural (NS) 5A resistance testing is not available.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested Venofer IV for treatment of her iron deficiency anemia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this setting.  This patient has symptomatic iron deficiency anemia that has failed oral supplementation.  Oral iron is difficult to take and most patients do not adhere to this form of therapy.  The patients hematologist appropriately prescribed Venofer, an iron sucrose formation with a low rate of infusion reactions, which has shown effective repletion by intravenous injection.  The current medical evidence supports iron sucrose for iron deficiency that has failed oral supplementation.  All told, Venofer IV is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 42-year-old male with an anterior mediastinal mass and pulmonary nodules; his diagnosis is unknown.  A needle biopsy was not sufficient for diagnosis and he requires a resection for a tissue sampling and biopsy.  The patient requested the video-assisted thoracoscopic surgery (VATS) procedure because he believes it is less invasive.  The Health Plan has denied authorization and coverage for the VATS procedure on the basis it is not medically necessary.VATS is the procedure of choice for lung biopsies, pleural biopsies, resection of mediastinal masses, etc. unless there is a clinical reason not to use this approach. This mediastinal mass, by CT description, can be resected via a VATS approach.  The VATS procedure is much less invasive than the sternotomy and should be utilized in this clinical context.  Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cold cap (scalp cooling) therapy.The submitted documentation supports that the services at issue were medically necessary. Chemotherapy induced alopecia is a well-known side effect of taxane-based chemotherapy as well as anthracycline based treatments. In one study, about 80% of patients (80/98) had persistent alopecia from taxane therapy. Since alopecia is a known side effect from taxane based chemotherapy, the condition has its own diagnosis and treatment. The SCALP randomized clinical trial concluded that patients who underwent scalp cooling were more likely to have less than 50% hair loss after the 4th chemotherapy cycle compared with those who received no scalp cooling. In this case, the patient had taxane-based chemotherapy. Cold cap (scalp cooling) therapy thereby countered chemotherapy induced alopecia, one of the known side effects of taxane-based chemotherapy that impacts quality of life and mental well-being. Under these circumstances, cold cap (scalp cooling) therapy was medically necessary to treat the patients medical condition.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 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested Provigil for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that in this patients case, the requested medication is not likely to be superior over other available treatment options.  The current medical evidence does not support the use of Provigil in this clinical setting.  The superior efficacy of Provigil as an adjunctive treatment in major depressive episodes has not been established.  All told, Provigil is not likely to be of greater benefit for the treatment of this patient than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Anastrozole. Anastrozole is an aromatase inhibitor that has been used for the treatment of patients with male hypogonadism. Anastrozole increases testosterone levels by lowering serum estradiol levels and increasing gonadotropin levels. In patients receiving testosterone replacement with testosterone pellets, Anastrozole maintained therapeutic testosterone levels longer than men on testosterone pellets alone and have significantly less gonadotropin suppression and no adverse events. Anastrozole can help prevent and treat testosterone-induced gynecomastia. In this case, the patient has been treated with Anastrozole for several years to counteract the effect of painful gynecomastia without any untoward side effects. The lack of the medication would allow the patients estradiol levels to increase and promote painful gynecomastia. Therefore, Anastrozole is medically necessary as part of the treatment regimen for this patients male hypogonadism. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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 59-year-old female enrollee has requested continued skilled nursing facility services for the treatment of her multiple fractures. Findings:  The physician reviewer found that the patient was benefitting from skilled care. She had just reached minimum/CGA with transfers. The submitted documentation provides no rationale or support for discontinuing daily therapy just two days after the patient reached this level. The patient was clearly making progress and was likely to continue to benefit from therapy. No evidence has been provided that the patient had reached her current maximum potential as of the date in question. In light of the potential for progress, the patient should continue to receive SNF services. A re-evaluation should be performed two-weeks from the date of this decision to determine if the patient is continuing to benefit from the SNF services.
Appeal type: Urgent Care
Decision: Upheld

A 50-year-old female enrollee has requested urgent care services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergent or urgent 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.  Urgently needed out-of-network services are those obtained due to an unforeseen illness or injury while travelling outside ones services area when it would be unreasonable to delay services until a patient can return to her service area. This patient reported a three week history of back pain and dysuria. She developed urinary frequency two days prior to her urgent care visit. The patient denied fever, chills, or other acute symptoms. She had not sustained any recent trauma. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent or urgent basis. There was sufficient opportunity to contact her primary care provider.  The patients symptoms on the date of service at issue did not meet prudent layperson criteria for emergent or urgent care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergent or urgent care to jeopardize her health in these circumstances.