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

Nature of Statutory Criteria/Case Summary: The patient had been diagnosed with bilateral knee osteoarthritis. The patient reported bilateral knee pain. Physical examination findings included tenderness to palpation over the right knee medial and lateral joint lines. Tenderness to palpation was noted over the anterior medial aspect of the left knee. The patient had been treated with oral anti-inflammatory medication, corticosteroids, and physical therapy. In an application for independent medical review, the patient noted that prior hyaluronic acid knee injections provided favorable results. The patient has requested authorization and coverage for Supartz injections to both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz injections to both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of favorable results from prior viscosupplementation injections. Furthermore, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Supartz injections to both knees 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 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: Overturned

ature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for matrix-induced autologous chondrocyte (MACI) surgery (CPT J7330). Findings:  The physician reviewer found that Based on the arthroscopic findings, the provider recommended that the patient undergo MACI transfer, especially given patients large chondral defect. Focal chondral defects are common in the patellofemoral joint and can significantly impair a patients quality of life. The MACI technique has been improved over 20 years. The first-generation technique included a periosteal patch, which was changed to a type I/III collagen membrane, followed by a collagen membrane seeded with chondrocytes prior to implantation. Current medical literature supports a role for MACI for this patients patellofemoral cartilaginous defects (Hinckel and Gomoll; Chahla, et al.). Based on these findings, the requested MACI surgery (CPT J7330) 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 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three reviewers 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 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: Upheld

A 64-year-old male enrollee has requested chiropractic services for treatment of his back pain. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support the medical necessity of chiropractic services.  This patient had multiple chiropractic visits in the past. Per the submitted records, the patients symptoms continue to flare up on a regular basis.  The patient is not making additional therapeutic progress with chiropractic treatment.  The office notes do not support continued chiropractic services in this clinical setting.  All told, chiropractic services were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 19-year-old male enrollee has requested a single photon emission computed tomography (SPECT) brain scan for evaluation of his psychological disorders.  Findings:  Three physician reviewers found that The American Psychiatric Association (APA)/Council on Children, Adolescents and Families advises against the use of SPECT scans for diagnosis, indicating the clinical utility of neuroimaging techniques for planning of individualized treatment has not yet been shown and further research is needed to demonstrate a clinical role for structural and functional neuroimaging in establishing psychiatric diagnoses, monitoring illness progression, and predicting prognoses. Specifically, the Council report states that although knowledge is increasing regarding specific pathways and specific brain areas involved in mental disease states, at present the use of brain imaging to study psychiatric disorders is still considered a research tool. Additionally, the APA Practice Guideline for the Psychiatric Assessment of Adults outlines a comprehensive approach to diagnostic assessment and in reference to neuroimaging, the guidelines specifically state further research is needed to demonstrate a clinical role for structural and functional neuroimaging in establishing psychiatric diagnoses, monitoring illness progression, and predicting prognoses. In conclusion, there is currently insufficient and limited scientific evidence to indicate that the diagnostic imaging at issue was likely to be more beneficial for evaluation and treatment of this patient than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to 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. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive, genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa. These trials showed superiority of Epclusa to Sovaldi with ribavirin. Moreover, a delay in treatment may result in decreased survival. For these reasons, Epclusa 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: Medical Necessity
Decision: Upheld

The patient is a 57-year-old male who has adenocarcinoma of the kidneys with metastatic disease to the lung and retroperitoneum. He has requested reimbursement for human tumor cell in vitro chemoresistance assay services he received in December 2003. The Health Plan has denied the patients request indicating the services at issue were not medically necessary.Review of the medical literature does not support the use of chemoresistance assays for patients such as this patient. A recent article in the Journal Of Clinical Oncology concluded, the use of chemotherapy and resistance assays to select chemotherapeutic agents for individual patients is not recommended outside of the clinical trial setting. This statement summarizes the current status of the use of in vitro cell based assays, (including those involved in this patients case) to select chemotherapeutic agents for treating tumors. There is no clinical trial that is scientifically valid, which supports the routine use of such assays in renal cell cancer. Though there is interest in determining whether such assays may play a role in the future, to date they are of unproven efficacy. Furthermore, the combination of gemcitabine and Xeloda has been reported to have some efficacy in kidney cancer and it appears the combination could have been used in this case without in vitro sensitivity testing. As such, there was no medical indication for the services at issue.Based upon the information set forth above, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI) without dye.According to the American Pain Society, surgical referral for chronic low back pain should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year. However, there is mixed evidence for some of the most widely used interventional pain procedures, such as epidural steroid injections, facet injections, and radiofrequency ablation of the medial branch. Surgical procedures include spinal fusion or lumbar disc replacement. Additionally, lumbar degenerative disc disease without disc herniation, also known as discogenic pain, can be diagnosed as the pain source in the presence of a high intensity zone on the MRI. When the diagnosis is confirmed, appropriate treatment may be rendered, relieving the chronic pain. In this case, the patient was involved in a motorcycle accident in 2017 and has reported low back pain since then. An MRI scan of the lumbar spine is requested to make an accurate diagnosis with regard to the decreased height at L5-S1 prior to referral for invasive treatment. In light of the history of chronic low back pain lasting more than a year, he meets the American Pain Society criteria for surgical referral, and the MRI scan would therefore be appropriate. Therefore, the requested lumbar spine MRI without dye is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service 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: Urgent Care
Decision: Upheld

A 36-year-old female enrollee has requested emergency services on an emergent basis for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. 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. This patient presented with abdominal pain for two days. Although she described it as hard and cramping, she was not feverish, nauseated or vomiting. Although her appeal letter states she was experiencing chest pain, the chart specifically denies that the patient complained of chest pain or palpitations. The patient also had a known history of gastroesophageal reflux disease. It is unlikely that a prudent layperson in similar circumstances would have considered her health to be in immediate jeopardy. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an orthopedic consultation at a tertiary level facility. Findings:  The physician reviewer found that Patellar dislocations are complex and include many causes such as trochlear dysplasia, patella alta, a high tibial tuberosity trochlear groove distance, weaknesses of the vastus medialis obliquus or a lesion of the medial retinaculum. Recent studies have focused on the medial patellofemoral ligament (MPFL) and have shown that the MPFL is the most significant passive stabilizer of the patella. Following patellar dislocation, an MRI should be standard practice to detect an MPFL rupture, osteochondral lesions, or other risk factors for redislocation. An acute first-time patellar dislocation without osteochondral lesions and without severe risk factors for a redislocation should follow a conservative treatment plan. If surgical treatment is required, the best postoperative results occur when the MPFL is reconstructed.In this case, the patients history of continuing pain one year after an acute patellar dislocation is of concern. Although the patients MRI does not show a definite MPFL rupture, continued follow-up by the tertiary care provider will be necessary to make a definitive diagnosis and perform repairs as needed to achieve a good result. Accordingly, the requested orthopedic consultation at a tertiary level facility is medically necessary for treatment of the patients medical condition (dislocated patella).Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient's 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vimpat 100 mg tablet (quantity 60, day supply 30). Researchers note that while the mainstay treatment strategy for seizures is medication management, much like the prescription of any other pharmaceutical agent, a clinician must balance efficacy with adverse events, and provide consideration for cost, drug interactions, patient preference, and availability with the focus predominantly on an individualized approach, with patient autonomy at the forefront. The authors further note that lacosamide (brand name Vimpat) is used as monotherapy or adjunct therapy for focal-onset seizures in patients aged four years and up, and tends to be tolerated decently well, with dizziness, ataxia, and nausea being the most typically encountered adverse effects. Researchers note that it is important to understand drug risks and benefits and that there are both medication and patient-related factors that influence appropriate drug selection, with the goal being to provide the best chance for seizure freedom with the lowest risk for potential side effects. Medical literature report that for focal epilepsy, lacosamide may be considered to decrease seizure frequency. In this case, the patients seizures have not been controlled with Keppra. The provider has recommended Vimpat, taking into account the drug risks versus benefits, with the goal of achieving the best chance for this patient for seizure freedom with the lowest risk for potential side effects. Given that current medical literature endorses an individualized approach in seizure management with patient autonomy and preference is at the forefront, the requested medication is medically indicated. Therefore, Vimpat 100 mg tablet (quantity 60, day supply 30) 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 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: Upheld

A 60-year-old female has requested BRCA1 and BRCA2 genetic testing due to her diagnosis of personal history of premenopausal invasive breast cancer and stated family history of cancer.  Findings:  The physician reviewer found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.Well-established guidelines identify those individuals in whom genetic screening is warranted. A personal history of breast cancer at age 50 alone is not considered a sufficient risk factor for BRCA gene mutation carrier status to justify testing, unless accompanied by other indicators of increased risk. These include, in part, a history of a first or second degree relative with ovarian cancer or breast cancer occurring at an age younger than 50, or belonging to a high-risk ethnic group such as Ashkenazi Jewish descent. The National Comprehensive Cancer Network (NCCN) guidelines also recommend testing individuals with a personal history of breast cancer and a limited family history, that is, where fewer than two close relatives, in either lineage, have survived beyond age 45. Review of the documentation provided does not demonstrate these qualifying conditions are met in this case. In sum, the clinical details provided regarding the patients BRCA risk factors is insufficient to justify BRCA mutation screening, as specified by the consensus guidelines described above.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Cyramza for treatment of his hepatocellular carcinoma.  The physician reviewer found that there is a lack of support for the requested medication in this patients case.  There is a lack of standard systemic therapies approved for use in the second-line after failure of sorafenib for hepatocellular carcinoma.  Ramucirumab (Cyramza) was thought to have potential efficacy in this role.  However, a phase III clinical trial by Zhu and colleagues recently concluded that it offered no survival advantage over placebo.  Per the current medical evidence, the use of Cyramza in the treatment of hepatocellular carcinoma is not supported by clinical evidence.  All told, the superior efficacy of the requested medication Cyramza has not been established.  Final Result: Two reviewers determined that the requested medication 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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.