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 weekly individual psychotherapy (frequency). Findings:  The physician reviewer found that the documentation does not support the medical necessity for the requested frequency of the individual psychotherapy sessions in this clinical setting. The patient showed no evidence of suicidality from the time she transitioned to individual psychotherapy sessions in July 2016. Her mood has been consistently stable. She has been compliant on her medications, and she has gained insight with improved distress tolerance. Her weight remained stable. She reported fewer binge episodes. She was doing well, and she showed no evidence of deterioration after decreasing from weekly to every other week psychotherapy. She continues to show stable weight, energy, sleep, mood, and affect. The provider noted that the patient was continuing to work on interpersonal relationships, her career, and developing adaptive responses to stressors. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has requested for the prescription medication Lyrica for treatment of his pain.    Findings:  The physician reviewer found that Lyrica is approved for neuropathic pain secondary to diabetes mellitus and the herpes simplex virus. Lyrica use is similar to Neurontin in MS patients and is an appropriate use.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female has requested an MRI of the left lower leg for evaluation of her left leg pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure in this patients case.  The current medical evidence does not support the requested MRI of the left lower leg in this clinical setting.  There is insufficient evidence in the medical records supporting the requested diagnostic procedure.  Prior imaging of the left tibia and fibula were reportedly unremarkable.  Per the submitted documentation, there are no red flags which would warrant an MRI of the left lower leg at this time.  This patients physical examination lists no fever or soft tissue mass.  Rather, the medical records note severe plantar fasciitis.  All told, the requested MRI of the left lower leg is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left knee replacement surgery. Findings:  The physician reviewer found that this patients records do not support the medical necessity of the requested left knee replacement surgery. The patients poor health including obesity, poorly controlled diabetes, and heart failure with reduced left ventricular function make him high risk and a poor candidate for knee arthroplasty. In the medical literature, a study concluded that Morbid obesity significantly increased the risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty for infection. another study reported that patients with heart failure are more likely to have a longer length-of-stay, return to the operating room, and be readmitted. Additionally, they have a higher risk for at least one postoperative complication, myocardial infarction, and wound dehiscence. Left knee replacement surgery is not medically necessary and appropriate for this patient with poor and deteriorating health.Final Result: The reviewer determined that the requested surgery 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 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 54-year-old male enrollee has requested chiropractic/physical therapy services for treatment of his fibula fracture and cervical spine stiffness.  Findings:  The physician reviewer found that From the dates in question forward, the patient underwent a program for the ankle fracture with interventions that included modalities such as electrical stimulation and chiropractic manipulation. There is no peer-reviewed medical literature that demonstrates these modalities would be beneficial for treatment of the patients ankle fracture. There was also a report of therapeutic exercises, however no documentation of the specific exercises performed (e.g., on an exercise log) was provided. Also, there is an absence of primary documentation related to initial assessments of range of motion, function, etc. Additionally, no documentation of ongoing assessments with detailed demonstration of clinically significant progress was provided. These are all basic requirements for establishing the necessity of physical therapy (Rand). All told, the submitted documentation did not demonstrate any evidence of analgesic, health, and/or functional benefit that could be clearly attributed to this intervention. Based upon the documentation provided, none of the therapy services at issue were medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old male enrollee has requested Lunesta for treatment of sleep difficulties secondary to Parkinsons disease.  Findings:  The physician reviewer found that Parkinsons disease is associated with fractured sleep and patients often require sleep aids. A sleep aid is medically necessary for this patient. The Health Plan states they have denied coverage for Lunesta due to absence of a failed trial of Ambien. This patient has tried Ambien, and there is documentation indicating the Ambien caused intolerable side effects. Thus, it appears the Health Plan criteria has been met.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested  combination ledipasvir/sofosbuvir (Harvoni) 400 mg #90 tablets for treatment of her hepatitis C.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) 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. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (90 mg/400 mg) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni 400 mg #90 tablets is supported as medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested a portable oxygen device (E1390) for treatment of her obstructive sleep apnea. Findings:  The physician reviewer found that the requested device is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has mild obstructive sleep apnea (OSA) and a listed diagnosis of congestive heart failure (CHF). The standard of care for the treatment of OSA is continuous positive airway pressure (CPAP). The criterion for the treatment of OSA with CPAP is an AHI of 15 or greater. In this case, the patients estimated AHI during the home sleep study was 9.  However, for patients with hypertension, cerebral vascular accident (CVA) or heart disease, the criteria for treatment with CPAP is changed to an AHI of 5 or greater. Therefore, the patient meets criteria for treatment with CPAP because of the listed diagnosis of CHF. Thus, the standard of care treatment for this patients nocturnal, mild hypoxia is CPAP, not oxygen. Thus, oxygen during sleep is not clinically indicated. Although, it would be substantiated if despite treatment with the optimal setting of CPAP the patient continued to have significant hypoxia. However, there is no documentation to substantiate this. Furthermore, a portable oxygen device is indicated by objective documentation that during ambulation the patient has an oxygen saturation of 89% or lower. There is no documentation of hypoxia on ambulation. Therefore, she does not meet criteria for a portable oxygen device. Based on the medical literature and documentation submitted for review, requested device is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a fecal transplant for treatment of his Clostridium difficile (C. difficile) infection. Three physician reviewers found that the requested fecal transplant is likely to be more effective for this patient than other available treatment options. Cumulative experience from case series and reports shows that fecal bacteriotherapy has been used to treat relapsing C. difficile infection. Several studies and meta-analyses have demonstrated efficacy of FMT in the treatment of C. difficile-associated diarrhea in patients with recurrent disease after initial antibiotic therapy. Limited observational data also suggests that treatment with FMT is associated with resolution of C. difficile-associated diarrhea in patients with severe disease. Based upon the multiple studies published in the peer-reviewed literature, FMT has now become the standard of care for the treatment of recurrent C. difficile infection and is likely to be more beneficial for treatment of the patients C. difficile than any available standard therapy. Final Result: Three reviewers determined that the requested services are 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested pain medication, Norco for treatment of the enrollee who has a history of pelvic pain, severe cervical dysplasia, and dysfunctional uterine bleeding. Findings: The reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested medication in this clinical setting. In a study the authors noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In a study, the author noted that opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerability. Tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. The provider noted that opioid therapy was not appropriate for this patient. Instead, gabapentin and Cymbalta were recommended as well as acupuncture. There is no documentation that the patient has tried these alternative therapies with the exception of the one week trial of Cymbalta. Therefore, the requested pain medication, Norco is not medically necessary for the 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 anesthesiology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services received. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the dates 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services at issue were not necessary for treatment of an emergency medical condition. The patient presented with a one-year history of bilateral arm pain with numbness and tingling. She underwent a nerve conduction study. One month later she underwent carpal tunnel surgery. There was no emergent medical condition noted in the records submitted for review. Based on the clinical documentation submitted for review, the medical services provided were not emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested an MRI of the right breast for the evaluation of her right breast lump. Findings:  Three physician reviewers found that the utility of MRI is limited to problem solving in certain individuals. In a patient with a painful, possibly increasing, palpable mass, excisional biopsy would be indicated regardless of the MRI results. The proposed MRI is not likely to be of any additional clinical value in this setting. An excisional biopsy is the next appropriate step for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services. Findings:  The physician reviewer found that there is a lack of support in the documentation for the medical necessity for the requested services. He was medically and psychiatrically stable.  There was no evidence of danger to self or harm to others. The patient showed mild post-acute withdrawals. There were no emotional, behavioral, cognitive, or impulsive symptoms to have required additional residential treatment. He was not agitated or manic, and he showed no signs of psychosis.  He verbalized motivation and appeared to be working the program.  He had a plan to attend IOP and continue in AA.  He indicated that he had a sober support system in his friends. He no longer required the structure of a 24/7 setting and could have continued treatment in IOP.  Residential services were no longer medically necessary. As such, he did not require 24 hour nursing and medical supervision at a residential level of care. Therefore, the residential treatment center services during the dates of service in question were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

 A 19-year-old male enrollee has requested for reinduction chemotherapy and haplo-compatible T-cell-depleted transplant with multiple post-transplant donor lymphocyte infusions for treatment of his acute myelogenous leukemia (AML). Findings:  The physician reviewer found that there is extensive research in this area at the present time, and the results are promising. For a patient such as this patient, transplant with multiple DLIs is the only potentially curative treatment alternative, and may be effective even in the face of aggressive AML.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested authorization and coverage of an ABI Vest. The Health Plan denied the request indicating that the requested equipment is not medically necessary for the treatment of the enrollees bronchial problems.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the breasts for evaluation of her medical condition.  The physician reviewer found that the submitted documentation supports the requested diagnostic procedure in this clinical setting.  This patient has a very strong family history of breast cancer, and her most recent mammogram noted extremely dense breast tissue.  The extremely dense tissue described on her mammogram markedly limits the utility of standard mammography.  While the risk in this patient has not been calculated in the records provided, the family history and extremely dense breast tissue are factors which are suspicious for increased lifetime susceptibility to breast cancer.  Due to the limited use of mammography as an adequate screen in this patient and the marked increased sensitivity of MRI for cancer detection in the breast, the requested MRI of the breasts is medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested a repeat colonoscopy for evaluation of her colonic polyps. Findings:  The physician reviewer found that considering this patients personal history of polyps coupled with her mothers diagnosis of colon cancer at age 60, it is reasonable for this patient to be followed in 5 years with a repeat colonoscopy. Despite the fact that the patients previous colonoscopy was negative, the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology concur that, colon cancer prevention should be the primary goal of screening. To that end, Brooks and colleagues recommend patients with a personal history of hyperplastic polyps be followed with a colonoscopy in 10 years. However, given this patients additional factor of her family history of colon cancer, the requested diagnostic procedure is indicated five years after the previous study. Thus, the patients request for the follow-up diagnostic procedure is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested Tarceva for treatment of her lung cancer.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient presented with inoperable advanced non-small cell lung cancer, an adenocarcinoma.  In this patients case, the EGFR mutation was an alteration in exon 18, which is most likely a missense mutation.  Some of the more common mutations detected are within exons 18 or 21 or deletions in exon 19.  All of these mutations correlate with response to tyrosine kinase inhibitors.  Exon 18 mutations, such as G719X, confer a 53% to 60% response rate to Tarceva or gefitinib.  Thus, the current medical evidence supports the use of Tarceva as medically necessary in this patients case.