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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  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 hepatitis C, genotype 1 infection regardless of fibrosis stage.  For these reasons, Harvoni is medically indicated for the treatment of this patient. 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 59-year-old female enrollee has requested authorization and coverage for a continuous glucose monitor Dex Com 7, a Medtronic insulin pump Paradigm 523, and supplies for both the Dex Com 7 and Paradigm 523.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested equipment in this patients case.  She was diagnosed with type 2 diabetes and she has severe gastroparesis.  As noted by the medical records, laboratory evaluation has revealed a low C-peptide level.  This patient requires insulin, and this needs to be adjusted in order to achieve normal glucose levels.  She has attempted multiple doses of insulin, without success in controlling her diabetes.  It is medically necessary for the patient to improve her diabetes control.  The insulin pump and continuous glucose monitor have been demonstrated to improve diabetes control and hemoglobin A1c in adult patients.  The requested continuous glucose monitor is an effective tool in conjunction with the insulin pump to adjust the patients insulin doses to a better level of control and to prevent wide glucose fluctuations.  In this patients case, the requested continuous glucose monitor Dex Com 7, Medtronic insulin pump Paradigm 523, and supplies for both the Dex Com 7 and Paradigm 523 are medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for WalkAide for treatment of the enrollee, who has history of right foot drop, functional gait disorder, and pressure ulcer of the right foot. Findings: Three physician reviewers found that the requested equipment is documented extensively in the medical literature as beneficial for central nervous system neurological injuries but not for peripheral nervous system pathology. While the provider stated that WalkAide will provide dorsiflexion assistance in this patients case, the current studies are lacking.  There is a lack of peer reviewed literature to support a rationale or mechanism by which the requested treatment would be effective or operational for a peripheral nervous system lesion as described in this patients case.  In sum, WalkAide is not likely to be more beneficial than the standard treatment options for this patient.Final Result: The three reviewers determined that the requested equipment 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: All three physician reviewers are board certified in physical medicine and rehabilitation and are actively practicing. The reviewer 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

The patient has requested reimbursement for air and associated ground ambulance transportation. Kidney transplantation is the treatment of choice for most patients with end-stage renal disease. A successful kidney transplant improves quality of life for the majority of patients when compared with maintenance dialysis. Multiple studies comparing the survival rates between patients accepted for kidney transplantation who have undergone surgery with those accepted for transplantation but who have not yet received a renal allograft have found that patient survival is substantially improved with kidney transplantation than with dialysis. In this case, ground transportation would have prevented the patient from receiving the kidney transplant. Per evidence-based literature, due to increased morbidity from end stage renal disease, the air ambulance and associated ground ambulance transportation provided were medically necessary for this patient. 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 internal medicine with subspecialty certification in nephrology 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 40-year-old female enrollee has requested continued outpatient psychotherapy for the treatment of her major depressive disorder, posttraumatic stress disorder and dissociative identity disorder. Findings:  The physician reviewer found that this patient does indeed have a complex grouping of psychiatric symptoms that appear to have improved with relatively limited psychopharmacotherapy and relatively frequent psychotherapy. The literature recognizes the difficulties associated with the treatment of the patients conditions, but does not suggest a fully established method of treatment. The treating physician proposes a relatively long period of continued treatment, and the Health Plan feels it should be essentially curtailed. The patients current regression, the nature of her psychopathology and her response to treatment since it began suggest that it would not be clinically wise to curtail her psychotherapy. However, the duration that her physician now advises is lengthy and possibly excessive. Three additional months of outpatient psychotherapy at a frequency not to exceed twice a week is medically indicated and appropriate. This should enable therapy to continue for the present time. It should also allow for treatment termination and/or treatment modification to be planned in an adequate and appropriate manner.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg. A study reported patients with alopecia areata frequently experience marked impairment in psychological well-being, self-esteem, and may be more likely to suffer from psychiatric comorbidities. In this case, the patients alopecia areata has progressed to alopecia universalis, affecting scalp, facial, and body hair. The patient has tried and failed standard treatment for alopecia areata, and the provider has recommended tofacitinib to treat the patients severe disease. Given that current medical literature supports the use of Janus kinase (JAK) inhibitors following failed treatments of first and second line therapies, in this clinical setting, the requested medication is medically indicated. Therefore, Xeljanz 5 mg is medically necessary for the treatment of this patient.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 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: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested a breast MRI for an evaluation of her breast nodule.  Findings:  The physician reviewer found that The standard of care for a patient such as this, with a new palpable breast mass, is a diagnostic mammogram and breast ultrasound. At this time, the medically appropriate imaging study for this patient is a diagnostic mammogram and ultrasound. Breast MRI is usually used as an adjunct to mammography and ultrasound and is not performed in lieu of mammography/ultrasound. The use of breast MRI is reserved for a certain patient population including those patients with newly diagnosed breast cancer when there is concern of multifocal or bilateral disease; those patients with past surgery for breast cancer when there is concern of recurrence at the scar; and in screening patients with the BRCA gene mutation. This patient does not meet any of these criteria.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with chronic low back pain and lumbar post-laminectomy syndrome who requested authorization and coverage for Percocet and Soma. The Health Plan has denied the request as not medically necessary. Findings:  The physician reviewer found that the CDC (Centers for Disease Control and Prevention) clinical practice guidelines do not recommend the prescription of opiates for non-malignant pain. Further, the patient had a positive toxicology screen. Prescribing opiates after a positive toxicology screen is not acceptable practice as defined by the Federation of State Medical Boards (FSMB). Chronic use of Soma would be off-label.  It was approved for short-term use only by the FDA (Food and Drug Administration). The requested medications are not medically necessary, and the Health Plans denial should be upheld.Final Result: The reviewer determined that the requested medications 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 anesthesiology with a 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

Nature of Statutory Criteria/Case Summary:  An enrollee requested knee replacement surgery without the requirement to first quit smoking for treatment of his left knee degenerative joint disease.   Findings:  The physician reviewer found that the requested total knee arthroplasty at the left knee is supported as medically necessary for treatment of this patients advanced degenerative osteoarthritis. Imaging has been obtained which confirm advanced changes. There has been a trial and failure of treatment with standard therapies. The patients BMI and weight is not a contraindication to surgery. According to the medical literature, obesity does provide a greater risk of perioperative complications but the studies quoted describe morbid obesity. This patients BMI is not considered morbidly obese. Further, nicotine addiction is not cited in the medical literature as a contraindication to total knee arthroplasty. The medical literature noted that for some patients addicted to nicotine, smoking cessation is impossible for them to achieve. While it would have both general health and positive microvascular changes, in this patient it is not achievable and should not be a contraindication to a total knee arthroplasty. Given that this patient has been treated with adequate conservative measures, the requested knee replacement surgery without the requirement to first quit smoking is medically necessary for treatment of this patients advanced degenerative osteoarthritis.Final Result: The reviewer determined that the requested surgery 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 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 45-year-old female enrollee has requested a mastopexy procedure for the treatment of her breasts. Findings:  The physician reviewer found that a mastopexy is rarely reconstructive in nature. In this instance, the patient was appropriately treated with reduction mammoplasty. The mastopexy would not lead to improved function. In addition, the mastopexy would not provide more than a minimal improvement in the patients appearance. Mastopexy in this case would not be considered a reconstructive procedure under Californias reconstructive surgery law. Furthermore, there was no medical indication of need for the mastopexy at issue. The mastopexy was a cosmetic procedure.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for custom molded foot orthotics. Findings:  The physician reviewer found that this patient suffers with plantar fasciitis pain, with a biomechanical structural abnormality including a flexible pes cavus foot structure with overpronation upon stance. She is noted to have pain upon palpation to the medial arch bilaterally.  Custom functional orthotics are the standard of care for the treatment of painful plantar fasciitis.  These devices are fabricated from an impression made of the patients foot. They are created to hold the foot in a biomechanically normal or correct position, thereby taking stress off of the plantar fascia and alleviating pain.  Final Result: The reviewer determined that the requested equipment 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 podiatry 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 22-year-old female enrollee has requested authorization and coverage for L4-L5 spinal fusion surgery.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  Fusion in the lumbar spine is generally accepted as indicated in the presence of symptomatic instability resulting from trauma, tumor, or infection.  Low back pain without a pathomorphological correlation or an explainable functional deficit is not an indication for fusion.  For non-radicular back pain, fusion is no more effective than intensive rehabilitation.  The use of discography as a confirming study remains controversial, with post-discography surgical outcomes inconsistent, and reports of false-positive findings in normal subjects.  In this patients case, there is a lack of documentation of an intensive rehabilitation program, and no documentation of other studies, such as electromyography abnormalities, to indicate the need for surgery.  There is no documentation of instability or spondylolisthesis to warrant fusion in this case.  All told, the requested procedure is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 39-year-old female who has experienced chronic pelvic pain since approximately 1989. She had been evaluated by her primary care provider and several specialists without receiving a clear diagnosis or effective treatment for her pain.  In 2003 the patient experienced some relief with a trial of neurontin and was then referred to her current provider who diagnosed pudendal neuralgia. She was begun on a course of PT and injection of trigger points. Although the patients symptoms seemed to wax and wane, in general she experienced a marked improvement in her pain with PT, as evidenced by her decreasing pain medication requirement and her ability to resume activities such as sitting, driving, exercising, coitus and working part-time.  In December 2005 the patient had an accidental fall which appeared to exacerbate her pain and cause somewhat different symptoms which were subsequently addressed in her PT. Currently, the patients pain is described as manageable and she is able to sit for four hours with moderate discomfort and is able to work part-time. The patient has requested authorization for continued PT to treat her pelvic pain.  The Health Plan denied her request based upon a determination that continued therapy is not medically necessary.A critical issue seems to be whether the patients continuing PT falls into the category of long-term maintenance or whether it should still be considered therapeutic, and as such medically necessary. A  Maintenance Program is defined by the Health Plan as one that begins when the therapeutic goals of a treatment plan have been achieved or when no additional functional progress is expected to occur. In this case, the patient has not achieved her therapeutic goals as she still experiences pain (especially when attempting to increase her activity level), continues to have considerable functional limitations such as discomfort with prolonged sitting and has only resumed working on a part-time basis.  Moreover, in his letter of August 2006 her provider indicated the patients condition continues to improve and that a full recovery is expected with continued therapy. As it appears there is still an opportunity for functional improvement, continued PT should be considered therapeutic rather than maintenance at this point in time. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not in withdrawals  and  was medically stable.   There was no evidence to suggest that treatment at a lower level of care would have resulted in harm to the patient.  The patient required redirection but was beginning to develop insight into areas requiring work.  He needed ongoing treatment to continue to work on relapse prevention and coping skills, and receive necessary support.  However, he did not require treatment in a 24-hour setting for these purposes.  The patient could have continued this at a lower level of care such partial hospitalization program or intensive outpatient program.  All told, residential treatment center services were not medically indicated for the 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication utilizing the EsophyX device.  The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who presents with a history of gastroesophageal reflux disease (GERD).Findings:  The efficacy of transoral incisionless fundoplication (TIF) using EsophyX has been studied in randomized controlled trials. However, the conclusions are inconsistent: one large randomized trial including 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months; normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%. The study concluded that no long-term objective reflux control was achieved. The 2013 American College of Gastroenterology guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (moderate level of evidence). In 2013, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF using EsophyX with anti-reflux surgery. SAGES concluded that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for GERD in patients with complicated GERD (which the guideline defines as dysphagia or Barretts esophagus), both of which this patient has, and report that the long-term follow-up data for TIF with EsophyX is limited (ASGE Standards of Practice Committee). These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF that had been performed using EsophyX device. For these reasons, TIF utilizing the EsophyX device is not likely to be more effective than the available standard methods of treating this patients medical condition.Final Result: All three reviewers determined 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:  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.