Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency services provided an emergent or urgent basis for treatment of her medical condition.   Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not believe she was experiencing an emergency medical condition. The patients stated symptoms are not noted in the records submitted. There is a lack of clinical documentation demonstrating that the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. There is no documentation submitted showing the patients pain rating severity. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.  Moreover, it has not been established that criteria for urgently needed services were met. The patient had a known medical condition. There is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the she returned to the Plans service area. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. 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: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg tablets for eight weeks is medically necessary for this patient.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: Upheld

A 64-year-old male enrollee has requested a follow-up neuropsychological evaluation for an evaluation of his neurological condition. Findings:  The physician reviewer found that the literature supports the ability of neuropsychological testing to profile patients with brain injury and help differentiate organic cognitive complaints from those due to depression. It also can allow differentiation of varied causes of dementia such as fronto-temporal dementia. However, in this patients particular clinical situation, there is no evidence that the follow-up neuropsychiatric testing was likely to yield clinically useful information that would affect decision-making regarding the treatment of this patients condition. The patients head injury had occurred approximately five years ago. Furthermore, he had already undergone previous neuropsychological testing which demonstrated significant cognitive deficits. There was no indication for neuropsychological re-evaluation as there is a lack of evidence to support the contention that the results of this testing were likely to affect treatment recommendations. The providers recommendations of participation in adult day treatment and psychiatric intervention for depression could have been made absent the repeat testing.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier test. Findings:  The physician reviewers found that the initial biopsy report noted a follicular lesion with indeterminate results. The Afirma Gene Expression Classifier showed the lesion was benign. Afirma testing is considered standard protocol on all FNA testing done on thyroid nodules. Further, there is sufficient literature to support the utility of the Afirma testing in this clinical setting. For these reasons, the Afirma Gene Expression Classifier test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A 50-year-old female enrollee has requested Flector 1.3% patch for treatment of her ankle sprain. Findings:  The physician reviewer found that there is evidence in the literature indicating that patch usage as a drug delivery system may provide pain relief by a local action involving diclofenac accumulation, with a lower rate of gastrointestinal effects than noted with oral intake (Petersen and Rovati). The use of a gel offers similar pain relief to the patch in treating the pain associated with sports-related soft tissue injuries, and the most common adverse events noted were the skin reactions and gastrointestinal symptoms.  In this case, the problem is chronic rather than acute, and the patient implies that she anticipates continued usage of the patch rather than shorter term use for an acute problem. There is no mention of the use of diclofenac as an oral medication, nor any problems associated with oral intake of that medication. There is no report of other measures to reduce the problems associated with the use of other NSAID medications. There is no report of problems swallowing medications.  Since there appears to be a favorable response by the patient to diclofenac delivered by patch, and there is no documentation of a trial of the use of this medication in oral form, the medical necessity for the use of a patch is not demonstrated.  All told, Flector 1.3% patch is not medically indicated for this patient.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings: The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the date of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. The psychiatric services provided on were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency is defined as a patient who is an imminent danger to herself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation, homicidal ideation, delusions, and delirium. Per documentation, the patient had none of these symptoms. The patients Clinical Institute Withdrawal Assessment for Alcohol (CIWA) and Clinical Opiate Withdrawal Scales (COWS) scores were unremarkable. The patients vital signs were stable. The nurses note stated that the patient did not have any withdrawal symptoms. Urine drug screening was positive for methamphetamine, cocaine, benzodiazepines, and opioids. However, the documentation does not demonstrate that a psychiatric evaluation or risk assessment was performed. Based on the clinical documentation provided, the patient did not receive psychiatric emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees medical condition. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is 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: Overturned

A 47-year-old female enrollee has requested bariatric surgery (biliopancreatic diversion with duodenal switch) for the treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure has a proven track record that is superior to that of the gastric bypass Roux-en-Y operation. This includes resolution of co-morbid conditions and percentage of excess weight loss in addition to a better lifestyle that does not include the complication of the dumping syndrome. The Health Plan suggests that dumping syndrome is a rare finding (less than 5%), whereas published scientific data (see Sugerman and colleagues, and Pories and colleagues) demonstrates a much higher incidence of dumping syndrome (greater than 50%). The patient is an appropriate candidate for the duodenal switch procedure, which should be covered as medically necessary in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 56 hours of licensed vocational nurse (LVN) level of care and two visits registered nurse (RN) supervision weekly for three months.Findings:  The physician reviewer found that  records provided for review document that this patient has multiple medical problems as a result of prematurity and Prader-Willi syndrome. The provider noted that the patient has required treatment in the emergency department, and he has been hospitalized multiple times with acute respiratory illnesses, including infection with COVID-19. Despite the patients acute and chronic issues, his medical condition is currently stable. The patients daily care includes services that can be safely and effectively met by a trained caregiver (Parab, et al.; Nageswaran and Golden). Overall, the patient does not require the services of skilled nursing providers. There is mention of maternal anxiety related to the patients care. However, the records do not document that the severity of illness interferes in the parents ability to manage the care of the patient or her other child. Thus, the records do not support an indication for skilled nursing assistance. For these reasons, the requested 56 hours of LVN level of care and two visits RN supervision weekly for three months is 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 pediatrics with subspecialty certification in pediatric critical care 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 78-year-old female enrollee has requested for Supartz injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the current medical evidence does not support Supartz injections in this clinical setting.  Viscosupplementation is an accepted part of the treatment of osteoarthritis of the knee.  However, viscosupplementation is most suitable for patients with mild to moderate disease and is more effective in patients with non-radiologically severe osteoarthritis. Jorgensen and colleagues performed a multicenter, randomized, placebo-controlled, double-blind study of 337 patients with knee osteoarthritis.  The authors concluded that intra-articular injections of hyaluronan did not improve pain or function in patients with moderate to severe disease activity.  All told, Supartz injections were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic cancer susceptibility panel testing for evaluation of the enrollees carcinoma of the small bowel.  Findings:  Two physician reviewers found that the diagnosis of small intestine tumors is often made in late stage due to typically non-specific symptoms at time of presentation. In recent years with the wide use of next generation technology to assess the molecular profile, multi-gene analysis has become more efficient. Current practice is to assess the molecular profile in order guide the choice of standard and novel therapeutic options. In colorectal cancer, the presence of KRAS, NRAS, and BRAF mutations direct standard therapy options. The presence of a RAS mutation, limits the utility of standard therapies. Due to the rarity of the tumor, evaluation of patients for clinical trials is recommended and screening necessitates tumor molecular analysis. For this reason, the use of next generation sequencing based multi-gene panel testing is clinically indicated to evaluate the treatment options available to this patient given the rarity of her tumor.  Final Result: Two reviewers determined that the testing at issue 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator implant procedure. The records document that this patient has failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea. There is adequate evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of patients with OSA with hypoglossal nerve stimulation or Inspire airway stimulation. The stimulation treatment for apnea reduction (STAR) trial showed that upper airway stimulation provides significant improvement in sleep-related quality of life outcome measures, with effects maintained across a five-year follow-up (Woodson, et al.). The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA to be a safe and effective second-line treatment in patients who are intolerant or unable to achieve benefit with positive pressure therapy. All told, the requested hypoglossal nerve stimulator implant procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested hypoglossal nerve stimulator implant procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment 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 otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine 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: Upheld

A 60-year-old female enrollee has requested the medication Byetta for the treatment of her diabetes mellitus.  Findings:  The physician reviewer found that the patient has had type II diabetes since 2006. Her hemoglobin A1C in April 2007 was 5.6%, which is only slightly above the normal range. After Byetta, her hemoglobin A1C was noted to be 5.9%. The patient does not appear to have complications from diabetes. Based on the clinical information provided, Byetta is not indicated for this patient at this stage of her diabetes. Life-style interventions with or without a low dose of Metformin will most likely be sufficient to keep the patients blood glucose under control.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high intensity focused ultrasound (HIFU) noninvasive cancer treatment. Findings:  Three physician reviewers found that HIFU therapy for prostate cancer is a relatively new procedure. There is a lack of support for the services at issue for the treatment of prostate cancer. The safety and efficacy of this treatment is currently being evaluated. There is a lack of comparative clinical trials indicating that this form of treatment is superior to conventional treatment options. Therefore, HIFU noninvasive cancer treatment was not likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that 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: Physician reviewers 1, 2 and 3 are board certified in urology 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.