Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional x-ray (breast tomosynthesis) for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the diagnostic procedure at issue was likely to have been superior over other modalities.  Per the medical evidence, digital breast tomosynthesis as part of the normal screening mammographic study is associated with a decrease in call backs as well as increased detection of small breast cancers when compared to digital breast mammography without tomosynthesis.  The addition of breast tomosynthesis to the routine standard mammographic views has proven very useful in screening populations.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result:  Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Urgent Care
Decision: Upheld

A 28-year-old female has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient presented to an urgent care facility complaining of a one-week history of a non-productive cough, hoarse voice and chest discomfort associated with a sore throat, nasal congestion and fever. No specifics regarding the severity of the patients symptoms were recorded in the medical records provided other than chest discomfort and a sore throat. The physical examination revealed normal vital signs and pulse oximetry, normal pharynx and normal lung sounds. No laboratory or x-ray testing was completed. The patient was diagnosed with an upper respiratory infection, with fever, cough and throat pain. She was given a prescription for benzonatate (a cough suppressant) and Augmentin and was discharged with instructions to follow up with her primary care provider in two to three days. The patient reports that she did not have a cell phone or access to the internet to find out if there were any in-network urgent care facilities closer to her home.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 indicates that the patients symptoms had been ongoing for one week. In addition, she had no physical findings of a serious illness such as strep throat or pneumonia. Further, her pain level was not noted to be severe based on the descriptive language in the medical records. All told, a prudent layperson would not have sought immediate medical attention in this situation. The patients symptoms did not rise to a level of severity that would cause a reasonable layperson to believe that the absence of immediate medical attention would jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female is requesting physical therapy for the treatment of her cervical sprain. Findings:  The physician reviewer found that post laminectomy pain syndrome typically requires prolonged physical therapy treatments. Physical therapy is an established treatment option in the literature. Post laminectomy cervical strain often requires multiple sessions of physical therapy. The submitted clinical information demonstrates that this patient ultimately responded to physical therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 68-year-old male enrollee has requested Gralise 600mg for treatment of his pain.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  He has tried and failed to benefit from standard therapy, including medications and physical therapy.  The medical records noted that generic gabapentin caused gastrointestinal distress.  The current medical evidence supports the use of Gralise in this clinical setting.  The requested medication is supported in the peer-reviewed medical literature as a safe and effective treatment for several neuropathic conditions.  This patient demonstrates neuropathic pain per the clinical notes.  All told, Gralise 600mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested an Elite Seat flexion device for treatment of his cruciate ligament reconstruction.  Findings:  The physician reviewer found that the most common complication of anterior cruciate ligament reconstruction is loss of extension, which can be functionally worse for patients than their preoperative instability.  Preventable surgical etiologic factors have been identified and have been advocated.  Early range of motion and avoiding flexion are important postoperative considerations.  However, stretching the knee into full extension can be achieved via exercises and bracing, if needed, without medical devices.  There is a lack of high-grade medical literature of a disinterested nature supporting the efficacy of the proposed device.  Its marginal efficacy in comparison or in conjunction to an active stretch program for the knee has not been demonstrated in a conclusive manner.  The requested device is not part of rehabilitation protocols that are based on the evidence-based literature. Although this patient has had prolonged difficulties with his left knee range of motion, the proposed device would not be expected to significantly improve the patient's health or functional outcomes in comparison to an exercise and bracing program alone or in conjunction with an exercise and bracing program.  All told, the requested Elite Seat flexion device is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management System for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The 3 physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has evidence of GERD based on pH recording. However, the patient has benefited to a significant degree from Dexilant treatment, and as such he cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in the patients clinical setting must be approached with caution given his manometric evidence of peristaltic dysfunction which may predispose to procedure-associated dysphagia. In addition, LINX is not U.S. Food and Drug Administration (FDA)-indicated in patients with Barretts esophagus or sizable hiatal hernias. As such, the LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested procedure is 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 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.Physician reviewer number two 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg/100 mg for 12 weeks. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, treatment with Zepatier 50 mg/100 mg for 12 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for leukocyte histamine release test (CPT code 86343). This patient underwent leukocyte histamine release testing given her history of urticaria. According to current management guidelines for chronic urticaria, even though chronic autoimmune urticaria can be differentiated from chronic idiopathic urticaria by the presence of auto-antibodies, the etiologic, therapeutic, and prognostic value of this auto-antibody has not been established. According to the American Academy of Allergy, Asthma and Immunology (AAAAI), routine laboratory testing in patients lacking atypical features rarely yields clinically significant findings (Bernstein, et al.). Overall, the utility of leukocyte histamine release test has not been demonstrated in to provide improved health outcomes when compared to standard available testing. Therefore, the leukocyte histamine release test (CPT code 86343) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the leukocyte histamine release test (CPT code 86343) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in allergy and immunology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aimovig auto injections 70mg-ml.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine headaches. At issue in this case is whether the requested medication, Aimovig auto injections 70mg/ml, is medically necessary for treatment of the enrollees medical condition.Aimovig showed efficacy for chronic migraine headaches. two Phase II trials (one for episodic migraine and one for chronic migraine) and two Phase III trials for episodic migraine have been published demonstrating the efficacy and safety of erenumab in the prevention of migraine.Aimovig is Food and Drug Administration indicated for the treatment of chronic migraine headache that has failed two or more preventive medications.  The records indicate the presence of chronic migraine headache condition (more than 15 headache days per month).  The patient has reportedly failed 11 preventive agents.  Therefore, the medication Aimovig is medically necessary.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 neurology 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: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested Xolair for treatment of her asthma. Findings:  Two physician reviewers found that this patient has moderate to severe persistent allergic asthma, and she has been optimally treated based upon current medical guidelines.  However, her disease appears to remain largely uncontrolled.  She has had a positive response to Xolair, with no notable side effects.  A review of the medical literature shows that there may not be explicit clinical rationale to prohibit the use of Xolair for patients with IgE level greater than 700.  In this patients case, Xolair was and is likely to be of greater benefit than other available treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested for a breast MRI for her breast cancer screening.. Findings:  Two physician reviewers found that MRI of the breast is helpful in diagnosing multifocal disease, multicentric disease, axillary disease and contralateral disease. Proper evaluation in this setting would include an MRI of the breast which can help identify pathology in the contralateral breast or elsewhere within the left breast. Additional findings could affect the treatment and management of this patient who has a history of a mass that was not detectable on mammogram.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for urine tests [albumin to creatinine ratio (ACR) and glomerular filtration rate (GFR)]. Benarroch-Gampel and colleagues note that routine preoperative laboratory testing for ambulatory surgery is not recommended as neither testing nor abnormal results are necessarily associated with postoperative outcomes. In this case, the patients history does not indicate a need for further evaluation of renal function, such as a known bleeding diathesis or abnormal hemoglobin and hematocrit levels. In this clinical setting, given that the documentation fails to indicate a concern regarding renal function, the requested services are not medically indicated. Therefore, urine tests [albumin to creatinine ratio (ACR) and glomerular filtration rate (GFR)] are not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 urology with sub-specialty certification in pediatric urology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma.Findings:  There is a lack of peer reviewed evidenced base medical literature to support the superior efficacy of the services at issue in this patients case. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages from 0-IV. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class I consistent with a low risk of metastasis or Class II suggestive of a high risk of metastasis. A study noted that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class II. The researchers concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as Class 1 with a low risk of near term (within five years) metastatic disease. While DecisionDx-Melanoma signature may be an independent predictor of metastasis risk, more studies are needed to show its efficacy when compared to standard methods used to guide therapy or predict the risk of cancer. All told, DecisionDx-Melanoma gene assay was not likely to have been more beneficial for the evaluation of this patients medical condition than any available standard therapy. Final Result: All three reviewers determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in dermatology 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 27-year-old female enrollee has requested the medication Provigil for treatment of her depression.   Findings:  The physician reviewer found that there is growing support in the literature for the use of Provigil in the treatment of refractory major depression. The patient has tried various antidepressants and dosage adjustments without sustained improvement in her depressive symptoms. Alternative stimulant medications have also been tried. At this juncture, adjunctive Provigil is a reasonable approach and is known to be effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 51-year-old woman with a history of diabetes mellitus type II, hypertension, spinal arthritis and obesity. The patient reports she cannot stand for extended periods of time, experiences bone pain, and is unable to ambulate.  She has requested authorization and coverage for a standard wheelchair, which has been denied by the Health Plan.The patient does not meet nationally accepted medical necessity criteria for authorization of a wheelchair. There is no evidence the patient is bed or chair confined. The submitted documentation does not indicate that the patient has impaired strength or mobility. No description of the patients gait has been provided. As such, it has not been established that the patients ability to ambulate is impaired. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A 19-year-old male enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that a patient must be suffering from the sudden onset of symptoms, including severe pain, that a prudent layperson would believe the lack of immediate medical attention would result in serious jeopardy to his health. Although the patient did report pain, he was not taking any pain medication. Further, the pain was not acute in onset.