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

The parent of an 11-year-old male enrollee has requested physical therapy for treatment of the enrollees cerebral palsy post surgery. Findings:  The physician reviewer found that based upon the physicians notes the patient appears to be making progress after the surgery. However, no specific goals are established by the physician or the therapist for the patient. It is clear that ambulation is a goal; however, the providers do not specifically document where the patients function is prior to surgery or how his gait is changing with therapy. The providers also do not set specific goals for other activities of daily living or transitions. Although there is documentation that they are working on transitions from floor to stand and walking on knees, they set no short-term or long-term goals.  Physical therapy is standard of care post surgery for children with cerebral palsy, but no objective evidence has been provided documenting that the patient is making progress.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load.  Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks.  These guideline 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 infection regardless of fibrosis stage.  All told, Harvoni is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 51-year-old male enrollee has requested for an interdental fixation device for treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that long-term studies support the fact that many patients such as this patient may progress to more severe sleep disorders as well as mood disorders. Mandibular positioning devices are known to be useful in treatment of mild to moderate obstructive sleep disorders. Compliance is fairly good when compared to the use of a continuous positive airway pressure (CPAP) device. Clinical symptoms show significant reduction in apneas with this treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage of an MRI of the right knee for evaluation of pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for tacrolimus 0.03% for treatment of the enrollees vitiligo. Findings:  The physician reviewer found that Vitiligo is an autoimmune disease leading to destruction of melanocytes which are the cells in the skin which make pigment. This condition is not only a cosmetic issue as it is an autoimmune condition and carries the risk of development of skin cancers in depigmented skin. The use of tacrolimus ointment as a non-steroidal anti-inflammatory topical medication is reasonable and considered to be the standard of care. This patient has failed treatment with topical steroids including triamcinolone ointment and betamethasone ointments, as well as clotrimazole and gentamicin. Thus, the requested tacrolimus 0.03% is supported as medically necessary for treatment of this patients vitiligo. 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 dermatology 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

A 50-year-old female enrollee requested r the OVA 1 test for medical evaluation of her bilateral complex ovarian cysts, right greater than left.  Findings:  Two physician reviewers found that the use of the OVA 1 test in this clinical situation meets the U.S. Food and Drug Administration (FDA) guidelines which state that this test is indicated in women over the age of 18, with an ovarian/adnexal mass and not yet referred to a gynecologic oncologist. Although the OVA 1 test is not designed as a screening test, its greatest utility is in determining whether a gynecologic oncologist should be involved in their surgical care. The medical literature suggests that patients with ovarian cancer whose initial surgery is performed by a gynecologic oncologist have an improved outcome. Thus, the use of the OVA 1 test was likely to have been more beneficial for evaluation and treatment of this patients medical condition than any available standard testing.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services provided by a neurologist who specializes in the autonomic nervous system. Findings:  The physician reviewer found that there is sufficient support in the medical literature as well in the documentation provided for the requested services in this clinical setting. Postural orthostatic  tachycardia syndrome is a prevalent form of orthostatic intolerance affecting many individuals. Its cause is suspected to be multifactorial. The medical evidence suggests that optimal therapy for this disorder is uncertain, and most of the medications used for treatment of this disorder are off label.  As a result, effective management of this condition requires someone who has experience in training and treating the disease process. The medical literature recommends a multidisciplinary care plan to be guided by a clinician who has the appropriate training and experience with the patients condition. Experienced providers have been shown to maintain quality of care. In this patients case, the patient has seen several neurologists which have addressed several elements of the patients medical condition, including nonepileptic seizures and functional movement disorder. However, this patient has not been sufficiently evaluated for her autonomic dysfunction based on the documentation provided. The documentation provided by the patient, with regards to uncovered visits with autonomic specialists, indicates a comprehensive treatment plan that addresses the patients diagnosis. Therapeutic interventions have shown to benefit this patient. As such, an evaluation of her autonomic dysfunction by a neurologist specializing in that discipline is medically indicated and is well supported in the medical literature. In sum, services provided by a neurologist who specializes in the autonomic nervous system is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested a 12 week course of Sovaldi for medical treatment of her chronic hepatitis C genotype 2b. Findings:  Three physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested 12 week course of Sovaldi should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene testing.  Findings: Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) Guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study (trial). Should a patient have high risk results, treatment and surveillance recommendations would unlikely be altered. Therefore, the services at issue were not likely to be more beneficial than any available standard treatments for the patients medical condition.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 internal medicine, with subspecialty 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: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested  for partial hospitalization for treatment of the enrollees anorexia nervosa. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for pre-adolescent patients with psychiatric conditions is a challenging endeavor, especially those with eating disorders.  Per the American Psychiatric Association, the appropriate level of care is based upon the patient's overall physical condition, psychology, behaviors, and social circumstances. The current medical evidence supports partial hospitalization services in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breasts. Findings:  Two of the three physician reviewers found breast MRI has an important role in both screening and diagnostic settings. There are multiple clinical considerations in which MRI has become widely used. These include areas of asymmetry, architectural distortion, and distinguishing tumor recurrence versus scarring. Breast MRI may be a useful adjunctive tool when conventional imaging findings are equivocal, as in this clinical setting. The Health Plan has noted that an MRI should not replace a biopsy in clear-cut masses. However, in this patients case, it is unclear whether she actually has a mass. While a breast MRI should not be a substitute for a biopsy for a clearly defined tumor, the provider must be able to localize the most suspicious area to best direct a biopsy. An MRI can direct the biopsy and further exclude a tumor. Therefore, the requested MRI is likely to be superior over other available methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 1, 2 and 3 are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion for treatment of the enrollees back pain. Findings:  The physician reviewer found that the request for lumbar spinal fusion is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports lumbar decompression surgery for symptoms and findings that confirm the presence of radiculopathy and correlate with clinical examination and imaging findings. Single level lateral lumbar interbody fusion for the treatment of adjacent segment disease is supported as safe and effective. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. In this case, the patient presents with persistent and worsening low back pain radiating into the right buttock and left leg to the dorsal foot with numbness. He is status post previous L4-S1 posterior spinal fusion with instrumentation. He has a chronic left foot drop that has worsened with increased giving way, toe catching, and foot slapping. His signs and symptoms are consistent with neurogenic claudication. Clinical examination findings have documented motor deficits, sensory loss, and reflex changes consistent with imaging evidence of adjacent segment disease at L3-4 including disc bulge/extrusion and severe bilateral neuroforaminal narrowing. There is also imaging evidence of potential pseudoarthrosis on the left side, and diffuse idiopathic skeletal hyperostosis. The patient has failed conservative treatment, including physical therapy, home exercise program, water therapy, medications and chiropractic treatment. The proposed surgery is clinically indicated due to the significant adjacent segment disease at L3-4 with the anticipated need for wide decompression. This would result in temporary intraoperative instability and require stabilization at the L3-4 level, and extension of the L4-S1 fusion with instrumentation from L3 to S1. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the requested services are not medically necessary in this clinical setting. The documentation provided does not support this patients elevation to PHP level of care. From the notes received, the patients expressed depression and anxiety, as well as anger and aggression during IOP level of care, which are within the range of problems that can be contained within the IOP level of care program.  Initial IOP group notes show that the patient denied suicidal or homicidal ideation. All told, the request for partial hospitalization program services 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 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

A 19-year-old male enrollee has requested authorization and coverage for the prescription medication Focalin XR, at a dosage of 30mg per day for treatment of attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that it is not uncommon to utilize a higher dosage of a medication with a 200-pound adult who has documented ADHD. As trials of other medications have failed and this medication is effective, the higher dosage is clinically reasonable.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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 parents of a 4-year-old male enrollee requested authorization and coverage of physical therapy for the treatment of autism.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female enrollee requested a denosumab injection for medical treatment of her osteopenia with a history of osteoporosis.   Findings:  Three physician reviewers found that peer-reviewed medical literature does not support indefinite use of pharmacologic therapy for treatment of osteoporosis. Bisphosphonates have residual effects that last for years after discontinuation of treatment. In addition, extended use beyond five years increases a patients risk for atypical femur fractures and osteonecrosis of the jaw. This patients records indicate that clinically she is not fracturing and her bone density has improved over time with treatment. In the absence of documentation that the patients markers of bone turnover increasing or that the patient has sustained fractures, the requested denosumab injection is not supported as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Overturned

A 24-year-old female enrollee has requested emergency services for treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient had eaten food and later experienced throat swelling and a rash. Although no respiratory distress was noted in the Emergency Department upon arrival, she had been experiencing throat edema just prior to arriving at the hospital. Symptoms of throat swelling, tightness or itching can be signs of acute anaphylaxis, the course of which is quite variable. In this patients case, exercise-induced anaphylaxis would be a prime consideration due to the temporal relationship between the patients food ingestion and onset of symptoms while exercising shortly thereafter. The prudent course is to proceed to the Emergency Department for an emergent evaluation and immediate treatment, as these initially mild symptoms may progress to airway compromise. As such, the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize her health in this situation.