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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Pradaxa for treatment of her medical conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue.  Pradaxa is used for the treatment of deep venous thrombosis and pulmonary embolism in patients who have been treated with a parenteral anticoagulant for five to ten days; and to reduce the risk of recurrence of deep vein thrombosis and pulmonary embolism in patients who have been previously treated.  The Health Plan requires that Xarelto should be tried first and if the patient is unable to tolerate it then Pradaxa may be tried, and this requirement is medically appropriate.  In this case, the patient was treated with Pradaxa for a pulmonary embolism.  The patient did not receive any parental anticoagulant before initiating treatment with Pradaxa.  Furthermore, the patient had not tried and failed treatment with Xarelto.  All told, Pradaxa was not and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 internal 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: Upheld

An 84-year-old male enrollee has requested hyperthermia with either conventional radiation therapy or immune modulated radiation therapy for treatment of his bladder cancer.   Findings:  Three physician reviewers found that Hyperthermia with either conventional radiation therapy or immune modulated radiation therapy (IMRT) is not likely to be more effective for this patient than other available options. This patient has muscle invasive bladder cancer and the standard of care for this kind of tumor includes radical cystectomy, neoadjuvant chemotherapy and combinations of chemotherapy and radiation therapy. However, hyperthermia in addition to radiation therapy is not supported in the peer-reviewed literature. There is a lack of published data that supports hyperthermia for muscle invasive bladder cancer. Thus in absence of published clinical data, the requested treatment is not likely to be more beneficial than any available standard treatment for this clinical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested excision of a hymenal remnant (tag) for treatment of her hymenal tags.  Findings:  The physician reviewer found that vulvar skin disorders, which include hymenal remnants, are common and the symptoms are oftentimes chronic. The American College of Obstetricians and Gynecologists (ACOG) practice bulletin reveals that symptoms associated with vulvar skin disorders can interfere with a patients sexual function and sense of well being. Benign lesions that are symptomatic can typically be managed with simple procedures including cryotherapy, electrosurgery, or excision. Skin tags occur in approximately 25% of adults and the risk increases with age (Banik and Lubach). This patients records indicate that she may have a symptomatic vulvar skin tag due to rubbing by clothing or intercourse. However, the providers notes do not provide evidence of any complaints during physical examination or by history. In the absence of documentation of a symptomatic vulvar skin tag, the requested excision is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tub labor and delivery. The records provided for review document that this patient is pregnant and she has requested a tub labor and delivery. However, there is no documentation that the patient cannot undergo safe and effective care with conventional labor and delivery despite the COVID-19 pandemic or her language barrier. The medical literature does not support the patients preference for a water birth with a midwife. Researchers noted that there are concerns around neonatal water inhalation, increased requirement for admission to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric anal sphincter injuries (OASIS) with water immersion labor and birth. All told, the requested tub labor and delivery is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of her 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. 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 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. The patient had a concerning history which dominated multiple functional domains. The patient had been unable to achieve any meaningful sustained sobriety in an extended period of time. Further, the patient had significant psychiatric comorbidity in the presence of acute psychosocial stressors. Based on the medical records, discharge to a less restrictive setting would have been premature and resulted in undue morbidity, prompt relapse and re-admission. The patient was noted to be gaining insight and motivation for improvement, but still struggling with dysphoria, self-defeating behavioral urges and negative self-talk. The records demonstrate that the patient had not consolidated the treatment gains necessary to success in a less restrictive setting. The services provided during the timeframe at issue were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness. All told, residential treatment services were medically indicated for the treatment of 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for emergency department services. Findings: The physician reviewer found that the Health Plan has denied this request indicating the enrollee did not receive emergency medical services.  At issue in this case is whether the enrollee received emergency medical services on the date 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 emergency department services were not necessary for treatment of an emergency medical condition. In this case, the patient experienced the gradual onset of pain over several days. She was not febrile or toxic-appearing. Her pain was not severe. The patient did not require laboratory testing or intravenous pain medications in the emergency department. The patient was diagnosed with a cellulitis and was treated with oral antibiotics. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld

A 48-year-old female enrollee has requested bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Although this patient has a body mass index of 53.72, there is no documentation of any failed dietary efforts.  There is a lack of documentation regarding supervised or non-supervised weight loss.  In addition, the submitted records do not include a multidisciplinary evaluation.  This would include a dietary evaluation and a behavioral evaluation.  All told, the requested bariatric surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) for evaluation of the enrollees bilateral knee pain status post strain and bilateral patella subluxation. Findings: The physician reviewer found that the records do not show red flags to indicate immediate MRI on either knee prior to an attempt at conservative management including physical therapy. There is no evidence of fracture, effusion or instability of a major ligament such as the anterior cruciate ligament on physical examination. Conservative treatment including a regimen of physical therapy may improve the patients symptoms. Final Result: The reviewer determined that the requested diagnostic procedure is 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 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: Upheld

A 42-year-old female enrollee requested authorization and coverage of an intradiscal electrothermal therapy (IDET) procedure. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) four days/week, for ten weeks. McClintock and colleagues note that there is an abundance of data pertaining to the safety and efficacy of TMS for individuals with major depressive disorder. The American Psychiatric Association (APA) guidelines for the treatment of major depressive disorder recognize the safety and efficacy of TMS in the treatment of patients with a prolonged course of depression. In this case, the records document treatment refractory depression, as the patient has failed three antidepressant trials in addition to psychotherapy. The provider has recommended treatment with TMS. The records noted that the patient made significant gains with previous TMS therapy. However, the patient now is again suffering from an episode of recurrent, severe major depressive disorder, with passive suicidal ideation. Given that current medical literature supports the use of TMS for the treatment of refractory depression, the requested services are medically indicated. In this patients case, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS four days/week, for ten weeks, is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A 38-year-old female enrollee has requested an excision skin abdomen, CPT code 15830, excision skin abdomen add-on, CPT code 15847, immediate insertion prosthetic following mastopexy, CPT code 19340, and excision excess skin tissue, CPT code 15832 for treatment of her excess skin.  Findings:  The physician reviewer found that the patients current condition does not constitute an abnormal structure of the body.  The requested surgery would not primarily improve function but would improve the cosmetic appearance of an otherwise normal appearance.  Therefore, excision skin abdomen, CPT code 15830, excision skin abdomen add-on, CPT code 15847, immediate insertion prosthetic following mastopexy, CPT code 19340, and excision excess skin tissue, CPT code 15832, are not reconstructive in nature and are not medically necessary for the treatment of this patient.
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, one per day for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that there is sufficient support for the requested medication regimen in this clinical setting.  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 (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 regardless of fibrosis score. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with Zepatier for 12 weeks, regardless of NS5A resistance testing results. These guideline recommendations are based on high-quality clinical trial data. The current guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested Reclast for treatment of her osteopenia.  Findings:  The physician reviewer found that in this patients case, the bone loss has significantly progressed over two years. The patient has osteoporosis in L4 with a T-score of -2.6, and femoral neck T-score of -2.2, which is close to the osteoporosis score. As reported by Watts and colleagues, these findings place this patient at increased risk for compression fracture in the spine and fracture of the femoral neck. In the clinical studies on the effectiveness and safety of Reclast, Lyles and colleagues found decreased rates of fractures and fewer complications from femoral fractures. Therefore, the requested use of Reclast therapy for this patient has been demonstrated to be medically necessary for her care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollees small intestinal bowel overgrowth (SIBO). Findings:  The physician reviewer found that as noted in the medical literature SIBO is characterized by an increased number of endogenous symbiotic bacteria in the small bowel and can lead to uncomfortable symptoms such as abdominal distention as well as intestinal malabsorption and nutritional deficiencies. A variety of antibiotics have been used in the treatment of SIBO, including metronidazole, either alone or in combination with trimethoprim-sulfamethoxazole. Xifaxan is the antibiotic which has been most frequently studied in placebo-controlled trials for treatment of SIBO in adults, and overall has been shown to be more effective than placebo for normalization of breath hydrogen tests as a marker for SIBO resolution. In the one head-to-head study of Xifaxan versus metronidazole, Xifaxan was more effective and there were also fewer adverse effects and less patient drop-out in the Xifaxan arm. Currently, no direct comparison of Xifaxan versus metronidazole for treatment of SIBO exists in the pediatric population. However, colleagues provided support for the use of Xifaxan in the pediatric population. Further, colleagues noted that while severe side effects of metronidazole are uncommon, they are not always reversible. The more common side effects, which might lead to discontinuation of the medication, would also be very difficult for a young patient with developmental delay and autism spectrum disorder to report. For these reasons, the use of Xifaxan rather than metronidazole for treatment of SIBO in this patient with autism is appropriate as a first-line pharmacologic treatment and is supported as 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 pediatrics with sub-specialty certification in pediatric 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.