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

The patient is a 53-year-old female who has chronic hepatitis C, genotype 1, stage III. She was treated with Peg-Intron and ribavarin for 48 weeks in 2004 but relapsed at the completion of the therapy. She was then treated with Pegasys and ribavarin for 12 weeks followed by Infergen and ribavirin for 48 weeks. Three months after completion of her therapy she relapsed again and her HCN viral load in June 2006 was 101,960 IU/ml. The patient wishes to be retreated with high dose daily Infergen and ribavirin for 48 weeks.Daily consensus-interferon (Infergen) and ribavirin is being used in patients who have failed to respond to previous combination therapy. Therapeutic options for hepatitis C treatment failures include retreatment with pegylated interferon, Infergen plus ribavirin, maintenance interferon therapy, and watch and wait for the development of new agents.  Infergen induction therapy together with subsequent ribavirin combination therapy showed promising results in two clinical trials conducted by Kaiser et. al. Two more recent trials have corroborated the Kaiser findings and there is significant interest in the use of Infergen for the treatment of nonresponders and relapsers.  Although the proposed therapy is not yet FDA approved, it is being used extensively by hepatologists nationally and internationally to treat relapsers and nonresponders to previous combination therapy. Based upon the studies citied above, the patient is an appropriate candidate for Infergen and ribavirin combination therapy.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested acupuncture for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although there is literature supporting an acupuncture trial for symptom reduction and function improvement for chronic lower back pain, no evidence of sustained, significant, objective functional improvement obtained with previous acupuncture was provided to support the necessity of any additional acupuncture.  Based on the records reviewed, the patient is not presenting a flare-up of the condition, or a re-injury. The use of acupuncture for maintenance, prophylactic or custodial care is not supported by peer-reviewed literature.  All told, the requested acupuncture 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 oriental 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral removal of implants and bilateral capsulectomy with explantation. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. One medical study performed a systematic review of contracture management and noted that there was limited clinical evidence behind the surgical management of capsular contracture. In this case, the patients symptoms predate the diagnosis of a capsular contracture. There has been no other work-up to rule out other etiologies for the patients symptoms, and the records do not document that conservative therapy was attempted to relieve these symptoms. No photographs were submitted for review that confirm the diagnosis of capsular contracture. There is no mention of tenderness on examination during either visit with the plastic surgeon. There is no indication as to the reason for the rapid progression of a contracture between the two visits with the plastic surgeon, with progression from no contracture to a grade 4 contracture. The patients complaints of movement of the implants with bending over and pain do not imply capsular contracture and can be related to changes that can naturally occur in cosmetic breast augmentation over time. Additionally, the submitted documentation does not demonstrate that the requested services are reconstructive in nature. This patients medical condition does not constitute an abnormal structure of the body. There are no supporting photographs that document a capsular contracture in this patients case. Although the patient reported movement of the implants with bending over and pain, this does not imply capsular contracture. There is no evidence of congenital defects, developing abnormalities, trauma, infection, tumors, or disease in the records provided. Thus, the requested bilateral removal of implants and bilateral capsulectomy with explantation are not reconstructive in nature and are not medically necessary 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 plastic 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 Prolia 60 mg injection. This patient has a history of osteoporosis. In addition, the patient has gastroesophageal reflux disease (GERD), for which she takes omeprazole. The patient was reportedly unable to tolerate treatment with Boniva in the past. The patients provider has recommended treatment with Prolia. The most potent antiresorptive agent is Prolia, a monoclonal antibody to the receptor activator of nuclear factor-kB ligand (RANKL). Hildebrand and Kasi noted that Prolia is a bone anti-resorptive drug used to treat osteoporosis and other bone-related disorders. In a large, randomized placebo-controlled trial of 7,868 postmenopausal women with osteoporosis, biannual 60 mg subcutaneous Prolia increased bone mineral density by 9.2% in the spine and 6.0% in the hip when compared to placebo (Lorentzon, et al.). Prolia is indicated as therapy for postmenopausal female patients with osteoporosis at high risk for fracture, defined as patients with multiple risk factors for fracture, a known history of an osteoporotic fracture, or those who have failed prior osteoporosis treatment. Given these findings, the requested Prolia 60 mg injection is medically necessary for 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 subspecialty certification in endocrinology, diabetes, and metabolism 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 acupuncture. The records document that this patient experiences headaches. Although she experienced mild improvement with medication, the patient presented secondary effects, therefore the medication was discontinued. The available medical evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. In addition, the authors noted that there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. Moreover, researchers found that acupuncture exhibits certain efficacy both in the treatment and prevention of migraines, which is superior to no treatment, sham acupuncture and medication. Further, acupuncture enhanced the quality of life more than did medication. Given this support and the transformation of this patients migraine headaches, an acupuncture trial of eight sessions is supported as medically necessary. 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 oriental 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

A 77-year-old male enrollee has requested skilled nursing facility services and a swallow test for treatment of his medical condition.  Findings:  The physician reviewer found that the patient did not sustain an acute stroke.  He had deconditioning related to pneumonia.  He was treated with antibiotics with empiric coverage for aspiration and was placed on a modified texture diet.  Thus, the requested swallowing study is medically indicated and can be provided on an outpatient basis.  However, the patient was not making significant progress and was not meaningfully participating in therapies to substantiate a need for inpatient rehabilitation services.  Further therapy services could have been provided on a less intensive basis in the community setting.  There are no documented ongoing skilled nursing needs in this patients case.  All told, the requested swallow test is medically indicated in this patients case.  However, the records fail to demonstrate the medical necessity of the requested skilled nursing facility services.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested an electric wheelchair for the treatment of her quadriparesis. Findings:  The physician reviewer found that this patient has incomplete quadriparesis, neuropathic pain, spasticity, muscle weakness and early fatigue. She is at very high risk for falls as a result of her weakness, slowed gait and spasticity. As her gait is labored, she requires higher energy expenditures resulting in fatigue. Her hand dysfunction affects her ability to use other assistive mobility devices.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 14-year-old female enrollee has requested psychiatric residential treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that this patient has struggled with ego fragmentation that has produced a formidable symptom complex. This young patient requires intensive services to achieve the desired end state of identity formation and sustained euthymia in the absence of self defeating behaviors. Applying the American Psychiatric Association (APA) treatment guidelines, the medical records fail to demonstrate the medical necessity for psychiatric residential treatment services. The patient has been showing signs of improvement. She has been active in therapy, including family sessions, and she has been reportedly stable on medication. She has not been disruptive or self-injurious. There is no clinical impression offered by the providers to support the medical necessity for continued residential treatment. All told, the services at issue were not and are not medically necessary for treatment of the patients 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. According to recent guidelines, 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. Further, the guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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: Overturned

A 53-year-old female enrollee requested authorization and coverage for the medication Fosamax. The health plan has denied this request indicating that Fosamax is not medically necessary for treatment of the enrollees osteopenia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara every four weeks. The medical literature supports dose escalation of Stelara in this patients case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease. A significant majority of these patients were able to discontinue steroids. In this case, alternative therapies are limited, as the patient has failed other biologic therapy for Crohns disease. For these reasons, Stelara every four weeks is medically necessary for the treatment of 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

The patient has requested authorization and coverage for a nuclear stress test. Based on the records provided for review, this patient presents with complaints of exertional dyspnea. The provider noted that the presence of diastolic dysfunction on echocardiogram (ECHO) prompted concern for cardiac amyloidosis. However, ECHO did not reveal left ventricular hypertrophy to support a diagnosis of cardiac amyloidosis. In addition, there is no documentation of low voltage on the patients electrocardiography. Based on the documentation provided for review, the requested nuclear stress test is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested an electromagnetic bone growth stimulator for the treatment of her bilateral pars interarticular fractures. Findings:  The physician reviewer found that electrical bone growth stimulators are not indicated and have not been proven effective for treatment of stress fractures. Thus, use of the device for an L5 stress fracture would not be deemed necessary in this case. This patient had complaints of back pain.  An MRI was felt to show probable left L5 pars defect, and a subsequent CT scan was felt to show bilateral pars defect more prominent on the left. Electromagnetic bone growth stimulators are not indicated for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for mastectomy coupled with nerve grafts and sensory re-innervation and breast reconstruction to include implants. The enrollee tested positive for the BRCA1 gene mutation. She has a family history of breast cancer in her mother. She has been doing surveillance with breast exams, mammograms, and magnetic resonance imaging (MRI) for years. She underwent a risk-reducing bilateral salpingo-oophorectomy (BSO), as well as removal of a uterine polyp. During the procedure, there were findings consistent with bilateral ovarian cancer. She was referred to a gynecologic oncologist and began chemotherapy. She underwent an abdominal hysterectomy and omentectomy. She is now requesting coverage for a mastectomy, coupled with nerve grafts and sensory re-innervation, and breast reconstruction to include implants. The enrollee states the procedure she is requesting is superior to the one available through her health plan, which results in cessation of breast sensation and causes numbness to the upper body. This outcome is not associated with the nerve-graft procedure. The surgeon indicates that when done through a team approach at the time of mastectomy, carefully combining nerve preservation and grafting, women have the opportunity to maintain their breast and nipple sensation after nipple-sparing mastectomy and immediate reconstruction; thus greatly reducing the potential morbidity of the procedure. The enrollees risk-reducing surgery includes a bilateral mastectomy. The medical literature for invasive breast cancer list appropriate procedures for reconstruction, which include autologous tissue transplantation (pedicled TRAM flap, microsurgical flaps from various areas of the body), latissimus dorsi flaps or breast implants; +/- tissue expanders. There is no Level I evidence that indicates nerve restoration is appropriate to maintain sensation. This surgery has not evolved to the point where it is considered part of the standard of care. An analysis of  studies in the peer-reviewed literature regarding breast neurotization (nerve transfer) indicated variability in the methods used in the studies and inconsistent measurable outcomes across studies. The data demonstrates postoperative sensation returns spontaneously and unpredictably.  Significant study design discrepancies exist, making it difficult to combine data and assess results. To effectively study breast sensation and this procedure, future investigation will depend on standardizing the way in which breast sensation is measured.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic and reconstructive 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested partial hospital program/day treatment program services for treatment of her behavioral health issues. Findings:  The physician reviewer found that the literature shows the need for and success of the partial hospitalization program/day treatment program is the subject of debate. A study by Abbate-Daga and colleagues concluded that further investigation is required to make DH [day hospital] treatment [programmes] measurable and comparable. Based on a review of the literature and a review of this patients records, the medical necessity of the partial hospitalization program/day treatment services is not established. The patient could have been appropriately treated in an intensive outpatient program during the dates of service at issue.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested for medical transportation for treatment of her Sjogrens syndrome and fibromyalgia. Findings:  The physician reviewer found that the patients lower extremity strength was described as 5 out of 5. Her recent laboratory work was stable. She is able to ride the local bus without problems. The patient is not confined to a chair, bed or stretcher. She does not need safety equipment and can ride in a car.
Appeal type: Urgent Care
Decision: Upheld

A 36-year-old female enrollee has requested services on an emergent basis.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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.Review of the submitted clinical information indicates the patient presented to the Emergency Department with a headache that was not associated with fever or a focal neurologic deficit. The patients pain level was documented as moderate (6 on a scale of 1 to 10).  There is no medical record documentation confirming the presence of severe pain. Nor is there evidence of the presence of signs or symptoms that would cause a prudent layperson to believe his or her health was in serious jeopardy. All told, a prudent layperson would not have reasonably believed this to be an emergency medical condition and would not have sought immediate medical attention in an Emergency Department.