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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the fecal calprotectin test (CPT Code 83993) received on 12/20/18. The Health Plan has denied the testing at issue as investigational. The patient presented for an evaluation on 12/19/18, secondary to a diagnosis of Crohns disease. The provider noted that previous treatments have included prednisone, Remicade, Humira, Pentasa, and Simponi. On that date, the provider indicated she has been stable on Stelara every six weeks, for at least three months, with a last injection on 10/26/18. The patients current complaints included distension, reflux pain, and loose bowel movements approximately two to three times daily. The fecal calprotectin test was ordered and reported as normal.Findings:  Two out of three reviewers found that various studies have found that fecal calprotectin correlates with endoscopic findings of inflammation and serum markers of inflammation in Crohns disease.  Further studies have found that fecal calprotectin is useful to assess disease activity in Crohns disease . The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease recommend fecal calprotectin to assess disease activity in patients with Crohns disease. Additionally, the most recent American College of Gastroenterology guidelines for the management of Crohns disease supports the use of fecal calprotectin testing in the assessment of Crohns disease activity.  Final Result: The reviewers determined that the requested test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with a subspecialty certification in gastroenterology, 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: Upheld

The patient has requested authorization and coverage for Viibryd 80 mg. In the medical literature, there is a lack of randomized controlled trials demonstrating that Viibryd 80 mg per day is more effective than placebo or Viibryd 40 mg for the treatment of major depressive disorder. According to the U.S. Food and Drug Administration (FDA), Viibryd can be taken at 80 mg per day if the patient is receiving concomitant CYP3A4 inducers for more than 14 days. The records provided for review do not demonstrate that the patient will be taking a CYP3A4 inducer with Viibryd 80 mg. The provider noted that the patient is an ultra-rapid metabolizer based on history of failed trials of previous medications. However, pharmacogenetic testing, or blood levels of Viibryd at lower doses that demonstrate that the patient may be a rapid metabolizer, have not been reported to confirm the patients rapid metabolizer status. Based on the available documentation and medical research, the maximum effective dose of Viibryd is 40 mg per day. For these reasons, the requested Viibryd 80 mg is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anastrozole tablets. Findings: Testosterone replacement therapy can lead to high levels of estradiol and symptoms such as breast tenderness and enlargement. These symptoms can be treated with estrogen antagonists such as anastrozole. Aromatase inhibitors can also lead to increased testosterone levels. In the medical literature, a study noted that the long-term efficacy and safety of aromatase inhibitors has not yet been established in malesand their routine use is therefore not yet recommended. Similarly, another study concluded that aromatase inhibitors are not recommended as treatment for functional hypogonadism because of insufficiency as well as a decrease in bone mineral density. The records provided for review document that this patient does not have reported side effects from testosterone replacement therapy. The provider charted that the patient has obtained adequate testosterone levels with their current treatment testosterone cypionate injections. However, the addition of an estrogen antagonist for hypogonadism and low testosterone treatment is not supported in the peer-reviewed medical literature. For these reasons, the requested anastrozole tablets are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar facet joint injections. There is sufficient support for the requested services in this patients case. Before performing radiofrequency ablation of the medial branch, a dual set of diagnostic blocks are required, both of which must produce 80% or better pain relief for the expected length of the local anesthetic. In this patients case, one set of blocks produced 90% pain relief.  Therefore, a second set is medically reasonable. The medical evidence supports the requested services in this clinical setting. Therefore, the requested lumbar facet joint injections are medically necessary for the 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Zepatier 50/100 for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that 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 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 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 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.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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for trigger point injections. The records document that this patient is undergoing treatment for occipital neuralgia, chronic migraine without aura, and neck pain. The provider reports that the patient has tried and failed multiple medications including antidepressants, anticonvulsants, beta blockers, triptans, and NSAIDs. The medical records note that the patient previously underwent occipital nerve blocks with reduction in symptoms. However, there is a lack of documentation that the patient has been treated with trigger point injections in the past. A progress note stated the patient would benefit from tendon injections especially for their neck pain and migraine attacks. The provider did not report that these injections were performed. The current medical literature and guidelines suggest that trigger point injections are appropriate as adjunct therapy in the treatment of headache disorders with the presence of active trigger points on physical examination. With regard to the request for trigger point injections in the context of migraines and occipital neuralgia, Madore and colleagues noted that, the addition of trigger point injections did not lead to a significant increase in length of benefit over occipital nerve blocks alone. Similarly, Krel and Mathew concluded that, there is limited efficacy data regarding trigger point injections. All told, the current request for trigger point injections are not medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in pain management 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 Harvoni for treatment of his 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 regardless of fibrosis stage.  All told, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (cell-free fetal DNA-based prenatal screening).Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this patients case. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening and does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, genetic testing (cell-free fetal DNA-based prenatal screening) performed was likely to have been more efficacious than other methods of evaluating this patient.   Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics and is 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

A 42-year-old male enrollee has requested  for two additional days of hospital care for treatment of her right total knee arthroplasty. Findings:  The physician reviewer found that a total knee replacements have a length of stay of three postoperative days.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.  Findings:  The physician reviewer found that the patient is a 53-year-old female who presented to the emergency department with a seizure that had resolved. The patient was visiting her son in the hospital when she began to feel diaphoretic and lightheaded. A nurse witnessed the patient have a convulsion and subsequently lose consciousness for 45 seconds. The patient denied head trauma, chest pain, or sensory or motor changes. Her past medical history included hypertension. Differential diagnoses included seizure, vasovagal, orthostasis, and anemia. Her vital signs were normal. The patient was fully oriented. No cranial nerve deficits were noted and muscle tone was normal. An electrocardiogram (EKG) showed a sinus rhythm with occasional premature complexes and a prolonged QT interval. A computed tomography (CT) scan of the head was negative for any acute findings. Laboratory data was significant for a troponin of less than 0.01 and was otherwise unremarkable. The patient received intravenous fluids for hydration. The patient was assessed with syncope, unspecified and discharged. The patient has requested reimbursement for emergency medical services provided. 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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient was a visitor at the hospital when she sustained loss of consciousness and convulsive activity witnessed by a medical professional. The differential diagnoses included seizure or syncopal convulsions. An EKG, telemetry monitoring and laboratory testing were necessary to assess for cardiac syncope due to arrhythmia or critical aortic stenosis. A head CT was also necessary to rule out an acute intracranial process that could present as new onset seizures. The services provided meet criteria for emergency medical services provided. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. 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 43-year-old female enrollee has requested authorization and coverage for the gastric sleeve procedure for treatment of her medical condition status post gastric banding placement.  Findings:  The physician reviewer found that based on review of the available records, the patient is symptomatic from the lap band with dietary intolerance and band removal has been approved. The request for conversion to laparoscopic vertical sleeve gastrectomy (LVSG) is not medically necessary. Although the patient is still morbidly obese with a BMI of 35 and has hypertension, the requested procedure, band to sleeve conversion is not supported in the medical literature as safe and effective in this clinical setting. The LVSG is a standard primary treatment of morbid obesity. The specific technical considerations necessary to perform an optimal sleeve with a high pressure system has been shown in published studies to be associated with increased morbidity and risk of leak after LAGB procedure, in contrast to the laparoscopic Roux-en-Y gastric bypass. In addition, there are no updated dietary or behavioral evaluations to establish that this patient is an appropriate candidate for revisional or repeat bariatric surgery at this time. All told, the requested surgery has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested  immunoadsorption therapy for treatment of his medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The medical records document coronary vasospasm, a possible autoimmune mechanism and ongoing chest pain reported to be refractory to medication.  One note reported only minimally abnormal autoantibodies to usual receptors mediating vasospasm.  Additionally, the description of ongoing chest discomfort is atypical for angina since it is worse with standing and worse with arm movement.  There is a lack of evidence in the scientific literature supporting the efficacy of immunoadsorption treatment for the diagnosis of coronary vasospasm.  In summary, it is not certain that autoantibodies are the cause of the patients cardiac condition based on the documentation provided, his current symptoms as documented are not clearly anginal, and the efficacy of treatment with immunoadsorption therapy is not proven.  Therefore, the requested immunoadsorption therapy is not medically indicated 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 internal medicine with sub-specialty certification in cardiovascular disease 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.