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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavyret, three times daily for eight weeks. Currently, the general position of experts in hepatology is that all patients chronically infected with hepatitis C should be treated. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) state that data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus eradication. Moreover, the guidelines noted that the panel continues to recommend treatment for all patients with chronic hepatitis C virus infection, except those with a short life expectancy that cannot be remediated by hepatitis C virus treatment, liver transplantation, or another directed therapy. Furthermore, treatment for nearly all with chronic hepatitis C is also the recommendation of the California Department of Health Care Services. All told, the requested Mavyret, three times daily for eight weeks, is medically necessary for treatment of this patients 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 internal medicine with subspecialty certification in infectious 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the guidelines 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. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` For these reasons, the requested treatment with Harvoni 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: Urgent Care
Decision: Upheld

A 24-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patients upper respiratory symptoms had commenced gradually over several days. Although she was experiencing chest tightness with deep breaths, this was not noted to be severe, nor did she report fever or shortness of breath. The patient had normal vital signs, and the only study obtained in the Emergency Department was a chest x-ray. The patient did not require any oxygen or other medications in the Emergency Department. 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 the criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female with type I diabetes, peripheral neuropathy and lower extremity pain. Her provider noted she is not able to walk more that one half mile. The provider also reports she cannot propel a manual wheelchair due to weakness, fatigue and carpal tunnel syndrome. The record did not include an objective assessment of the patients strength, range of motion, or mobility skills. The patient has requested authorization for a power-operated vehicle (POV). Her request was denied by the Health Plan based upon a determination that the equipment is not medically necessary.The records provided for review are not supportive of the patients need for a POV. There is no specific evaluation of the patients mobility and no clear indication of the need for a POV within the home.  In January 2006 the patients provider noted that she is able to walk up to one half mile. Upper extremity weakness is noted, however medical necessity criteria for a POV requires that the patient be bed or chair bound without the equipment. As that is not the case for this patient, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male requested authorization and coverage of a full-body CT scan for the treatment of chronic abdominal and back pain.  The health plan denied the enrollees request indicating that the requested CT scan is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested CT scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested continued inpatient stay for treatment of her deep vein thrombosis. Findings:  The physician reviewer found that the patient was admitted with an acute deep vein thrombosis with pain, constipation and to rule out a complicating pulmonary embolism.  She was treated effectively with anticoagulation, intravenous fluids, pain medication and appropriate stool softeners.  She responded well, as evidenced with improved regulation of bowel movements, pain control, normalization of renal function and effective anticoagulation without acute bleeding. Her vital signs remained stable throughout hospitalization.  The medical condition of deep vein thrombosis can safely be treated as an outpatient with anticoagulation (Scarvelis and Wells).  The admitting team had arranged appropriate care in a skilled nursing facility at discharge.  Several factors can necessitate inpatient hospitalization, including poor medical compliance, need for parental narcotics, active bleeding, severe high blood pressure, renal failure or thrombocytopenia.  The only factor that would apply to this patient is poor medical compliance, which would be improved with admission to a skilled nursing facility.  In summary, this patient could have been safely managed at a skilled nursing facility for further physical therapy, anticoagulation and laboratory monitoring. All told, continued inpatient stay at a treatment facility from the dates in question was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested Botox injections (200 units) for treatment of his cervical dystonia and Parkinsons disease.  Findings:  Three physician reviewers found that cervical dystonia, also called spasmodic torticollis, is the most common of the focal dystonias. In torticollis, the muscles in the neck that control the position of the head are affected, causing the head to twist and turn to one side. In addition, the head may be pulled forward or backward. Botox is an acetylcholine release inhibitor and a neuromuscular blocking agent indicated for treatment of cervical dystonia in adult patients. Multiple studies have demonstrated that Botox reduces the severity of abnormal head position and neck pain in this patient population. Further, through careful electromyographic (EMG) assessment of select muscles for injection, Botox therapy will frequently result in improved clinical benefit. This patient has documented evidence of cervical dystonia, which is not a manifestation of his Parkinsons disease. He has failed treatment with oral medications and Botox is FDA approved for the treatment of cervical dystonia. Thus, a trial with Botox is clinically appropriate in this circumstance and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old male enrollee has requested follow up care with a pediatric cardiologist for treatment of his Shones syndrome.  Findings:  The physician reviewer found that current guidelines recommend that just over half of adult congenital heart disease patients should be seen by a cardiologist with specific congenital heart disease expertise because they are at risk for serious complications (e.g., reoperation and/or arrhythmias) and premature mortality (Sable, et al.). Their expertise in treating these patients is far greater than the average adult cardiologist who receives limited training in congenital heart defects. As noted by Kovacs and Verstappen, Adult physicians have not been educated about the complexity of the adult with a congenitally malformed heart. In sum, it is medically necessary for this patient to be followed by a pediatric cardiologist who understands the natural history of congenital heart defects. As such, the medical necessity of the requested services has been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of good pain relief from viscosupplementation using Synvisc One injection of the left knee for treatment of osteoarthritis. Moreover, the patients symptoms have not substantially improved despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy. All told, the requested Synvisc One injection in the left knee 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a denosumab injection for treatment of her osteoporosis.  Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Denosumab is U.S. Food and Drug Administration (FDA) approved for the treatment of postmenopausal osteoporosis in women at a high or increased risk of fracture. Studies have demonstrated that treatment with denosumab leads to a decrease in the frequency of both vertebral and non-vertebral fractures. Denosumab is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has experienced adverse reactions to bisphosphonate therapy in the past and she has taken Forteo for the maximum approved time period of two years. For the reasons provided, the services at issue were likely to be a more beneficial treatment than standard medical therapy in this clinical setting. Final Result: Two reviewers determined that the services at issue were 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: All three reviewers are board certified in endocrinology and metabolism 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tadalafil 20 mg twice daily. Findings:  The physician reviewer found that On review of the medical records and current peer-reviewed medical literature, the requested tadalafil 20 mg twice daily is likely to be more beneficial for treatment of this patients Raynauds than any other available standard treatment. There is documentation that this patient has severe Raynauds due to systemic sclerosis with fingertip pain, digital ulcers, and dusky pale appearing fingers with areas of ischemia noted on the digits. The patient has failed to respond to or has been unable to tolerate other standard treatments for severe Raynauds such as calcium channel blockers, sildenafil, and epoprostenol. The patient is being treated with tadalafil 20 mg twice daily with good results for her severe Raynauds. Although there are limited data available, review of the medical literature does support the use of tadalafil for the treatment of patients with Raynauds in this patients clinical setting. Roustit and colleagues performed a meta-analysis of six randomized controlled clinical trials on the use of a phosphodiesterase type 5 (PDE-5) inhibitor in the treatment of patients with Raynauds. The authors concluded that the use of a PDE-5, such as tadalafil, significantly reduced the mean Raynauds condition score as well as the frequency and duration of ischemic attacks. For these reasons, the requested tadalafil 20 mg twice daily 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 tadalafil 20 mg twice daily 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 medication is 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 internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology 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

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested coverage for Humatrope for treatment of the enrollee's growth hormone deficiency. Findings:  The physician reviewer has found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient meets criteria for growth hormone deficiency, as her height is less than the third percentile for age, her bone age is delayed, her growth velocity is poor, and she has had a poor peak growth hormone response to stimulation testing. However, there is no difference in efficacy or adverse effect profile between various growth hormone products. Thus, there is no medical necessity for use of Humatrope brand name. Nutropin AQ is a satisfactory treatment for this patients diagnosis. There is no documentation that the patient had an adverse reaction to or cannot tolerate Nutropin AQ.  All told, Humatrope is not medically necessary for the 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 48-year-old female enrollee has requested a laparoscopic gastric banding procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient is seeking authorization for the Lap Band procedure. The medical literature has consistently shown the Lap Band is efficacious and is associated with less morbidity than the Roux-en-Y gastric bypass or the duodenal switch procedure. The Lap Band procedure offers the potential for significant weight loss and is medically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested tumescent liposuction for medical treatment of her lipedema.  Findings:  The physician reviewer found that the proposed tumescent liposuction meets reconstructive surgery criteria, the patient presents with lipedema, which is considered an abnormal condition. Her condition is a result of disease of fat accumulation. The documentation provided demonstrates that there is an abnormal appearance present and more than a minimal improvement can be expected from surgical treatment. Therefore, the requested tumescent liposuction does meet reconstructive surgery criteria.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested authorization and coverage for a gastrointestinal tract capsule endoscopy of the small bowel. The records document that this patient has had symptoms and elevated calprotectin with normal colonoscopy, suggestive of possible small intestinal Crohns disease rather than the current diagnosis of ulcerative colitis. Capsule endoscopy is useful for the diagnosis of Crohns Disease or determination of the extent of disease activity, and superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has been demonstrated to be superior to all current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Therefore, the test is supported by guidelines for the diagnosis of Crohns disease. For these reasons, a gastrointestinal tract capsule endoscopy of the small bowel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that a gastrointestinal tract capsule endoscopy of the small bowel is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested service is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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 42-year-old female enrollee has requested magnetic resonance imaging enterography for evaluation of her history of pain in the lower right groin area and right lower extremity numbness and tingling.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure.  This patient has known malrotation of the intestines with prior surgical repair of a volvulus.  She has ongoing episodes of severe abdominal pain.  The requested diagnostic procedure is a new imaging study that is most useful in the serial follow-up imaging of patients with known Crohns disease.   Thus, the current medical literature does not support the requested magnetic resonance imaging enterography in this patients case. In this clinical situation, the requested imaging modality is not the standard tool for evaluation. All told, the requested magnetic resonance imaging enterography is not medically necessary for the evaluation of this patient.