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

A 35-year-old female has requested coverage for past air ambulance transport services.  Findings:  The physician reviewer found that the patient is a gravida 4, para 0, Ab 3 female who was 32 and 2/7-weeks pregnant when her membranes ruptured and she began having episodic uterine contractions.  She presented to the Emergency Department (ED) and was admitted for observation and fetal monitoring.  The fetus heart rate did not become abnormal.  She was consulted on and physical examination revealed that the patient was 80% effaced and 1-cm dilated.  Laboratory tests confirmed that the vaginal fluid leak was amniotic fluid.  She was also noted to have a culture-proven group B strep urinary tract infection (UTI).  She was treated with penicillin for her UTI, Decadron to prevent lung disease associated with pre-term delivery, and terbutaline to inhibit additional contractions.  The treating physician consulted the perinatologist at a medical center, and the transfer was accepted.  The provider was concerned that ground transportation would take too long, with an estimated transport time of 1 hour and 10-minutes, and opted to send his patient via helicopter air ambulance transport, with a transport time of 20 minutes.  The transfer was accomplished without complications.  At the request of the provider at the receiving hospital, the patient was given magnesium sulfate IV during transport to further ameliorate uterine contractions. At issue in this case is whether a prudent layperson in the enrollees circumstances would have sought immediate medical attention. 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.Premature rupture of membranes is concerning for imminent delivery and the possibility of risk to the fetus life. A prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. The choice of transport from the emergency facility to the hospital was made by the physicians at those two facilities.  A layperson would not be expected to have the medical knowledge necessary to assess the pros and cons of ground versus air transport and would reasonably be expected to rely on the advice of the doctors involved in her care, which in this case was to utilize air transport. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency air transport to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Neulasta. In the medical literature, Smith and colleagues noted that prophylactic use of colony stimulating factor (CSF) agents is recommended for the prevention of febrile neutropenia in patients who are at high risk on the basis of age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. However, the National Comprehensive Cancer Network (NCCN) guidelines and American Society of Clinical Oncology (ASCO) do not support the use of one CSF over another for growth factor support in this clinical setting. In addition, updated guidelines from ASCO suggest that all preparations of CSF, including biosimilar agents, can be used for the prevention of treatment-related febrile neutropenia (Smith, et al). This patients provider has recommended treatment with Neulasta. While Neulasta may be more convenient due to less frequent dosing, Neulasta has not been demonstrated to be more effective than Neupogen, which has been approved by the Health Plan. All told, the requested Neulasta is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 authorization and coverage for vein embolization and the related medical services for treatment of the enrollees pelvic congestion syndrome. Findings:  The 3 physician reviewers found that the request for vein embolization and the related medical services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patients symptoms correlate with the imaging findings that are consistent with pelvic congestion syndrome. Embolization of the gonadal vein to prevent reflux and pelvic pressure is an established treatment modality for this condition. The proposed plan is reasonable and appropriate in this clinical setting. Accordingly, the request for vein embolization and the related medical services has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 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 number one is board certified in vascular 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.Physician reviewer number two is board certified in vascular 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.Physician reviewer number three is board certified in vascular 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 reimbursement and prospective authorization and coverage for hyaluronan injections to the bilateral knees every six months. An exhaustive review of medical literature pertaining to the viscosupplementation at issue reveals mixed results. Evidence suggests that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown as to which patients will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. Current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons (AAOS) indicate that the evidence is not conclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, guidelines reserve viscosupplementation for patients with a history of lasting benefit from prior injections and in carefully selected cases where treatment options are limited. In this case, the patient reports excellent results from viscosupplementation since 2014, with reduced need for taking non-steroidal anti-inflammatory drugs and discontinuation of opioids. Furthermore, the remaining treatment options are limited, with the alternative being a total knee arthroplasty. As such, hyaluronan injections received to the bilateral knees, every six months, were and are medically necessary for treatment of osteoarthritis of the patients knees. Final Result: The reviewer determined that the services at issue were and 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent guidelines issued, 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.  Per the guidelines, treatment-naive non-cirrhotic genotype 1 patients should be treated with Harvoni, or with Viekira Pak and ribavirin.  These guideline recommendations are based on multiple randomized clinical trials.  Although treatment of hepatitis C is necessary, based on medical literature, the information supplied in this case does not provide justification to support coverage of Harvoni over Viekira/ribavirin. No head-to-head clinical trials have compared these medications, and the patient does not have anemia, pregnancy, or other contraindications to ribavirin. Concern for Viekira-induced hepatic decompensation in cirrhotic patients does not apply to this non-cirrhotic patient.  For these reasons, the requested treatment with Harvoni is not supported as medically necessary for the treatment of this patients hepatitis C infection.  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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz. Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata including eyebrows, eyelashes and facial hair. Some autoimmune diseases are also linked with alopecia areata. Treatment is challenging and aims at the regrowth of hair. Although alopecia areata is not life threatening or painful, its onset and erratic nature disturbs the lives of many. Alopecia areata can negatively impact a patients self-esteem, body image, and self-confidence. It has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Researchers found that Xeljanz is effective in alleviating alopecia universalis without significant side effects. Given this support, the requested Xeljanz is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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: One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammagard infusions.Multiple sclerosis is a progressive immune disease affecting the central nervous system (CNS), causing neurological dysfunction. Multifocal inflammation of the CNS characterizes the disease and causes impaired nerve conduction. Multiple sclerosis is not a curable pathology; however, there are several medications that are approved by the U.S. Food and Drug Administration (FDA) and indicated for management. There is some evidence to suggest the possibility of benefit with the use of IVIG. When compared with a placebo, IVIG has been associated with disability improvement after one year. However, there is an absence of statistically significant improvement noted after two years. Furthermore, there is a lack of evidence that immunoglobulins can reduce the progression of multiple sclerosis. Despite some testable benefit, IVIG is not endorsed by national neurological groups, including the American Academy of Neurology. Guidelines only support the use of IVIG if conventional immunomodulatory medications are poorly tolerated or ineffective. There is limited evidence supporting the efficacy of Gammagard infusions in this clinical setting. In this case, the patient has been diagnosed with multiple sclerosis. The submitted documentation does not show a poorly tolerated or ineffective response to conventional immunomodulatory medications. There is a lack of support for the requested services in this clinical setting. Thus, Gammagard infusions are not medically necessary for the treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Partial Hospitalization Program for eight (8) hours a day. The medical documentation does not support the medical necessity of the requested services. On the date of the request, the patient endorsed only passive suicidal ideation without a plan or intent. The assertion that her labs had deteriorated is somewhat of an exaggeration, given that the results that were out of range were within one point of the high/low limits, with only amylase being mildly out of range. These `deteriorations` are not a sufficient reason to step up to a higher level of care. They can be easily monitored on an outpatient basis by sending the patient to a lab for a repeat blood draw. The patient had no self-harm urges or behaviors. She was medically stable and her psychiatric medications did not require a structured setting. She had enjoyed an extended period of sobriety, and her alcohol cravings did not require a structured setting either, as she was attending AA and had a sponsor. Although the patient reported dizziness, her vital signs were stable and she was not orthostatic. She was engaged, cooperative, and within normal range in terms of ideal body weight and BMI. The medical documentation does not reflect that the patients eating disorder behavior requires a structured Partial Hospitalization Program setting. The documentation reflects that she is aware of how to use coping mechanisms, that she is working on triggers, that she has insight, and that she does not require intense, multiple times per day (8 hours/day, several times/week) interactive face to face treatment with staff. She is not reported to be over-exercising. Her treatment plan has not required frequent revision, she has been medication compliant, and her family has been noted to be supportive. Therefore, the requested Partial Hospitalization Program (PHP) for eight (8) hours a day is not medically necessary for treatment of the patients medical condition.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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MiniMed 670G insulin pump. Findings:  The physician reviewer found that the Medtronic MiniMed 670G system was approved by the U.S. Food and Drug Administration with the following description: The Medtronic MiniMed 670G system is intended for continuous delivery of basal insulin (at user selectable rates) and administration of insulin boluses (in user selectable amounts) for the management of type 1 diabetes mellitus in persons, fourteen years of age and older, requiring insulin as well as for the continuous monitoring and trending of glucose levels in the fluid under the skin. The system is the closest to an automated closed loop system device for insulin delivery in the management of diabetes mellitus type 1. Leelarathna and colleagues have shown that closed-loop insulin delivery at home reduces mean glucose and increases time in target without increasing the risk of hypoglycemia in adults with relatively well-controlled type 1 diabetes.  In addition, studies are also demonstrating the deleterious effect of wide glucose fluctuations as a factor in the development of diabetes related complications. This patient has neuropathy, so it is important to bring her hemoglobin A1c to 7% with no hypoglycemia. Microvascular complications may be prevented or delayed if the hemoglobin A1c can be maintained at 7% or less with no hypoglycemia. As such, an automated insulin delivery device would assist in managing and controlling these wide glucose fluctuations. Moreover, this patient has retinopathy and neuropathy, so this feature is important. The MiniMed 670G is a closed loop system insulin pump with continuous glucose monitor that will automatically make corrections when the patient is trending to hypoglycemic or hyperglycemic range. This system will allow the patient to remain within the recommended target range, most of the time. With this system, the continuous glucose monitoring will communicate with the pump. The patient will be able to keep hemoglobin A1c closer to goal and while minimizing hypoglycemic and hyperglycemic events. The MiniMed 670G is a diabetes management device that utilizes advanced technology. As such, MiniMed 670G insulin pump is likely to be more beneficial than any other available therapy for the management of this patients diabetes type 1. Final Result: Two of the three reviewers determined that the requested device 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: Physician reviewers are  board certified in 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 58-year-old female enrollee has requested authorization and coverage for a bunionectomy on her left foot for the treatment of her bunion. Findings:  The physician reviewer found that the submitted medical records reveal no documentation of conservative treatment options. Although the radiographic findings are not above the minimum acceptable values for surgery specified by the Health Plan, if the bunion is chronically painful and fails to respond to conservative treatment (i.e., oral non-steroidal anti-inflammatory drugs, physical therapy, steroid injections, orthotics and immobilization), then a bunionectomy would be medically necessary. Therefore, the patient should undergo a trial of the above mentioned conservative measures; if these measures fail to provide relief, then the requested bunionectomy should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Hepatitis C virus direct-acting antiviral therapy should be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America.  The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C virus infection, namely those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of hepatitis C infection. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis.  This patient does not meet the criteria as high priority for treatment.  All told, the requested Harvoni for eight weeks is not medically indicated for the treatment of this patient. Final Result: Three reviewers 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 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.