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

A 20-year-old male enrollee has requested authorization and coverage for a duodenal switch procedure for treatment her morbid obesity. Findings:  The physician reviewer found that the patients BMI of 48 and co-morbidities he meets medical necessity criteria for weight loss surgery. The safety and efficacy of the duodenal switch is well established based on the available medical evidence including long-term follow-up of over 10 years. While the duodenal switch procedure is indicated for this patient, the submitted information lacks documentation that the patient has stopped smoking. Smoking is a contraindication to any weight loss surgery and documentation of smoking cessation should be obtained prior to authorization of the requested procedure.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested for the prescription medication Vyvanse for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that no untoward side effects were reported after a one-month trial of this medication and it was clearly beneficial. The prescribed dosage is within recommended guidelines. Continued treatment with Vyvanse is clinically appropriate for this patient.
Appeal type: Urgent Care
Decision: Upheld

A 29-year-old female enrollee has requested emergency services.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the said date. 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.Review of the submitted documentation demonstrates the patient had a sore throat for one day at the time she presented to the ED. She did not have a fever and her pain level is not documented in the medical records provided. Although the patient received antibiotics in the ED, her diagnosis was pharyngitis. While the patient indicates she has asthma and was concerned about potential breathing difficulties, she was not noted to be in respiratory distress in the ED and a diagnosis of asthma is not noted in her medical history. Based on the available documentation, the severity of the patients symptoms on the date in question were not such that they would cause a prudent layperson to believe she required immediate medical attention to avoid serious harm.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractor appointments twice per week or once per week. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has a chronic and stable condition that shows no sign of improvement, even with continuous care. She is requesting coverage for additional chiropractic care at a frequency of one or two visits per week. There is no documentation of re-injury or flare-up. The requested services are considered maintenance therapy and are not medically indicated. Therefore, chiropractor appointments twice per week or once per week are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in chiropractic care 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 61-year-old female enrollee has requested an enhanced external counterpulsation (EECP) for the treatment of her angina. Findings:  Two physician reviewers found that the patient has nitrate responsive chest discomfort that may represent angina given her known coronary disease. However, it is not certain the patients chest discomfort represents angina (no stress test demonstrating provocable ischemia). The severity, frequency, disability, and limitation of the chest discomfort are not documented, and medical treatment has not been optimized (long-acting nitrate or Calcium blocker not prescribed). Medical treatment needs to be optimized prior to consideration of EECP.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested comprehensive pain rehabilitation for treatment of the enrollee, who has a history of post-concussion syndrome with headaches, sleep disorder, pain disorder with psychological factors and somatic symptom disorder.  Findings: The physician reviewer found that a review of current medical literature support the use of interdisciplinary approaches to pain management in the pediatric population.  The interdisciplinary model of pain management is said to be more effective than isolated approaches to pain management. Research has also shown that more intensive programs tend to have a greater degree of clinical efficacy, in the form of short and long term improvement, than less intensive interdisciplinary treatment.  This has been demonstrated in comparative studies a few colleagues.  In this case, the patient is noted to have a longstanding history of chronic pain, primarily in the form of headaches which have been reported as refractory to most outpatient forms of therapy. The requested interdisciplinary pain program is through an out of network provider but the records indicate that the Health Plan has offered an in network interdisciplinary program. The literature does not show that provision of services from one specific provider group is more effective than what is offered by another. While there is a potential role for intensive pain management program for the treatment of this patient, the submitted documentation does not support that the requested services are medically indicated over the other.  Moreover, the records do not appear to show that the current interdisciplinary services offered by the Health Plan have been fully exhausted, at this time.  Therefore, based on the information stated above, the requested comprehensive pain rehabilitation program to include 15-day outpatient program is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology 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 thirty-five year-old male diagnosed with acute myelogenous leukemia (AML) is requesting one cycle of high dose chemotherapy and autologous stem cell transplantation. Cytogenetic analysis revealed inversion, which is a relatively favorable subtype of AML. The patient was induced into complete remission with chemotherapy.  Reviewers Findings:The reviewing physician found that autologous marrow (stem cell) transplant is superior to chemotherapy in preventing the relapse of AML and the use of high dose chemotherapy, and that autologous stem cell transplant for consolidation is likely to provide a better outcome than chemotherapy.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old male enrollee has requested Adderall XR 20mg per day for treatment of his deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  Attention deficit/hyperactivity disorder is a common disorder affecting approximately 7% of school-aged children. Per the current medical evidence, up to 65% of children with attention deficit/hyperactivity disorder will continue to have impairing symptoms into adulthood.  Adderall XR is a once-a-day psychostimulant medication consisting of a mixture of amphetamine and dextroamphetamine salts, and has long been a trusted intervention in the treatment of attention deficit/hyperactivity disorder.  Although concern has been raised in this case about the patients substance use comorbidity and the potentially addictive nature of stimulant medications, the diagnosis of attention deficit/hyperactivity has been documented.  The patient has tried both stimulant and non-stimulant medication alternatives.  He has reportedly done best on a reasonably-dosed stimulant medication.  Additionally, the stimulant preparation is extended-release which provides up to 12 hours of coverage with a single dose and thus minimizes the potential for abuse and rapid variance in serum drug levels.  Stimulant medication is the first-line treatment for attention deficit/hyperactivity disorder.  All told, the requested Adderall XR 20mg per day is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old male with chronic low back pain. He is status post a right hemi-laminectomy. The patient recently completed four weeks of physical therapy and has requested authorization and coverage for a Saunders traction unit for continued treatment of his remaining symptoms. The Health Plan has denied this request on the basis that the requested device is not medically necessary for treatment of the patients condition.This patient received physical therapy in a program that included traction with 80% relief in his back pain. The therapist instructed him in a home program. The Health Plan indicates the patients medical group is able to provide a standard traction device. Review of the clinical literature does not demonstrate that use of the requested Saunders traction unit results in a superior outcome over standard traction devices. As such, there is no medical justification for use of the requested device in this case. Therefore, I have determined the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Optune treatment and prospective authorization and coverage for future Optune treatment for treatment of the enrollees glioblastoma.  Findings:  The 3 physician reviewers found that the physician reviewer found Optune is a novel portable medical device that generates low intensity alternating electric fields. This treatment has been approved by the U.S. Food and Drug Administration for the treatment of glioblastoma. It is a helmet-like device that is attached to the scalp, and continuous treatment is recommended. This approval was based on a single controlled trial by colleagues of patients. The authors found that patients treated with the device had the same overall survival with residual glioblastoma as did those treated with chemotherapy, but with a much better toxicity profile. In this difficult to treat malignancy, there is sufficient data to support the use of Optune therapy. Therefore, Optune treatment was and is likely to be more effective than other treatment options. Final Result: The 3 reviewers determined that the services at issue were and 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 57-year-old female has requested coverage for past emergency services.  Findings:  The physician reviewer found that the patient presented to the emergency department with chief complaint of productive cough, congestion, dizziness, slight fever, shortness of breath and runny nose of two days duration. She reports a prior history of underlying lung disease for which she was followed by a pulmonologist. Vital signs in the emergency department included heart rate 99, respirations 18, temperature 98.1 degrees and oxygen saturation 99% on room air. The patient reported a 7 out of 10 pain level. Upon initial presentation, the patient exhibited labored respirations, cough, and decreased breath sounds. A chest x-ray was normal. The patient was assessed with upper respiratory infection, viral and prescribed guaifenesin 600 mg extended release.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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.Review of the submitted documentation demonstrates that the patient was experiencing symptoms of sufficient severity to cause a prudent layperson to seek immediate medical attention. Specifically, the patient reported acute symptoms of cough, shortness of breath, dizziness and fever. Additionally, the patient had a history of significant lung problems in the past which played a role in her decision to seek immediate medical attention. All told, it was reasonable for the patient to believe that the absence of immediate medical attention in this setting could cause serious harm to her health, as her symptoms were concerning for serious impairment of breathing, worsening infection and risk for sepsis, and other infectious complications. As such, the patient met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee has requested bilateral breast reduction for treatment of her symptomatic macromastia. Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the requested services.  The records document back and neck pain and intermittent downward radiating left arm numbness, pain and weakness.  The current medical evidence supports bilateral breast reduction in this clinical setting.  Breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain and skin breakdown. The Schnur scale has been developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive breast reduction surgery prior to surgery.  Given the absence of any breast cancer, as the amount removed is increased the procedure changes from a cosmetic procedure to a medically indicated reconstructive procedure.  In this patients case, the requested services are likely to relieve her current symptoms.  All told, bilateral breast reduction is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Anser ADA testing and Prometheus Anser IFX testing for evaluation of her medical condition.  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The patient was clinically doing well and had the gold-standard testing for disease activity; assessment and confirmation of mucosal healing.  Generally, low drug levels and presence of antibody correlate with loss of response. However, in this patient who was doing well she may need only a low level of anti-TNF (due to mild disease) to experience a benefit.  Navigating treatment based on the tests in question is not evidence-based.  All told, Anser ADA testing and Prometheus Anser IFX testing were not likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  Credentials/Qualifications: All 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 50-year-old male enrollee has requested Lyrica for the treatment of his limb pain and cervical stenosis. Findings:  The physician reviewer found that this patient has been diagnosed with neuropathic pain resulting from cervical spinal stenosis and has experienced pain relief with the use of Lyrica. Neither fluoxetine nor cyclobenzaprine have showed any efficacy against neuropathic pain and therefore are not indicated for management of this patients symptomatology. Although a tricyclic antidepressant could be used, the side effect profile of Lyrica is much better than any of these medications.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a PET/CT scan for an evaluation of her adrenal mass. Findings:  Three physician reviewers found that the evaluation of an adrenal lesion is a common clinical scenario. Typical work-up for such a condition would be: 1) thin-section non-contrast CT through the adrenal glands to determine its size, confirm the presence of a nodule, and measure its density or 2) A magnetic resonance imaging (MRI) scan of the adrenal with in phase/out phase scans. If a thin-section non-contrast CT had been performed, it may have confirmed a low density nodule which is benign. Either of the above-mentioned procedures would have been more suitable as a first-step diagnostic test. If either of these procedures were inconclusive, then a PET/CT could have been considered at that time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Per the AASLD/IDSA guidelines, treatment naive genotype 1 patients should be treated with Harvoni for eight weeks in patients with viral load of less than 6 million IU/mL. 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 genotype 1 hepatitis C regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni 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.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested Avastin therapy for the treatment of her breast cancer. Findings:  The physician reviewer found that Avastin in combination with paclitaxel has been shown to prolong survival in front-line advanced breast cancer therapy. Avastin has also been shown to significantly increase response rates in second-line therapy in combination with capecitabine (Xeloda). In the recurrent metastatic breast cancer setting, Avastin has shown a 9.3% objective response rate and stable disease in 16% of patients at six months as a single agent. In this instance, the patient has been exposed to known-active agents for breast cancer treatment without response. Avastin has been shown to have clinical benefit at various stages of breast cancer treatment and is medically appropriate for this patient.