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 Vascepa. Rosenson and Eckle note that for patients with high atherosclerotic cardiovascular disease (ASCVD) risk whose triglyceride levels remain at or over 150 mg/dL after lifestyle interventions and optimal therapy to lower low-density lipoprotein cholesterol (LDL-C), there is evidence suggesting that high-dose marine omega-3 fatty acid, specifically icosapent ethyl (brand name Vascepa), reduces cardiovascular risk. In this case, given that the records demonstrated that the patient had established ACSVD and a triglyceride level of 240 mg/dL despite treatment with Lovasa and Praluent, the requested medication is medically indicated. Therefore, Vascepa is medically necessary 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 certifications in cardiovascular disease and in clinical cardiac electrophysiology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopy, surgical, esophageal sphincter augmentation procedure. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. Findings:  Two of the three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature has not established that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Therefore, laparoscopy, surgical, esophageal sphincter augmentation procedure is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are 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 sub-specialty certification in gastroenterology 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 oral appliance therapy treatment and temporomandibular joint (TMJ) treatment for treatment of the enrollees sleep apnea and TMJ disorder. Findings: The physician reviewer found that TMJ and orofacial pain disorders can have a wide variety of causes. Stabilization splints are one of multiple types of removable appliances that are commonly used to treat TMJ disorder. In general, stabilization splints are used in conjunction with other therapies like behavior modification, non-steroidal anti-inflammatory drugs (NSAIDs) or other pharmacotherapy, and physical therapy. When used as a short-term adjunct to other therapies, oral appliances can be reasonably expected to improve the patients symptoms. Mandibular advancement devices are a type of removable appliance used to reposition the mandible in a more forward position during sleep, allowing more room for the passage of air. These devices are effective for the majority of patients, especially for patients unable to tolerate CPAP. In this case, the patient was unable to tolerate CPAP. A mandibular advancement device is medically necessary to improve his OSA symptoms. Based, on the clinical documentation submitted for review and support in the peer-reviewed literature, the request for oral appliance therapy treatment and TMJ treatment is medically necessary for treatment of the patients medical condition.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 dentistry 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

The parent of a 14-year-old female enrollee has requested a stem cell transplant evaluation for treatment of the enrollees systemic scleroderma. Findings:  Three physician reviewers found that this patient has rapidly progressive systemic sclerosis with diffuse skin involvement, gastrointestinal involvement and pulmonary involvement. The skin and internal organ involvement rapidly progressed in less than one year. Currently, there is no specific therapy shown to reverse disease, and randomized trials of immunosuppressive agents have not shown long-term benefit. This patient has already undergone a sufficient trial of both Cellcept and methotrexate, without any improvement.  Additionally, she has had three doses of Cytoxan, with worsening pulmonary function.  The results of current randomized trials assessing hematopoietic stem cell transplant for systemic sclerosis will not be available until next year. However, preliminary studies are promising, as are smaller non-randomized studies and case reports. Long-term follow-up in one trial of 26 patients with systemic sclerosis that underwent hematopoietic stem cell transplant revealed a five-year survival of 96%.  All told, in this patients case, the requested stem cell transplant evaluation is likely to be the most efficacious treatment option.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old male enrollee has requested reimbursement for laboratory tests (Coronary Health Disease - Assessment of Emerging Risk Factor (Measurement of Homocysteine) for evaluation of the enrollees risk for coronary heart disease.   Findings:  Two physician reviewers found that the patient has a history of sleep apnea, hyperlipidemia and right bundle branch block and no known coronary artery disease. The patients blood pressure measurements are documented to be normal. The patient underwent laboratory testing including measurement of homocysteine to assess his risk for developing coronary artery disease. The Health Plan denied reimbursement for the homocysteine test stating it was investigational for the purpose of evaluating risk of developing coronary artery disease. Based on the records provided for review, the patient is a 66-year old male with some coronary risk, but no known coronary artery disease. In this circumstance of primary prevention of coronary disease, guidelines for the evaluation and management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including homocysteine (Greenland, et al). Moreover, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Specific to homocysteine, randomized trials with available therapies to reduce homocysteine levels have not shown significant outcomes benefits (Albert, et al). The only circumstance where specialized testing above may be considered appropriate is in very selected cases of secondary prevention where standard risk factors are not present to a sufficient degree to explain a cardiovascular event occurrence and treatment change may result from the testing obtained. Neither of these factors is present in this case. Therefore the diagnostic testing at issue was not likely to be more beneficial than standard modalities for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication Mavyret 100mg-40mg three times daily for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 3 patients should be treated with Mavyret 100-40 mg (three tables daily) for eight weeks. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is medically necessary for 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 Internal Medicine, with a subspecialty certificate 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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 Harvoni for treatment of his hepatitis C.  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  There is sufficient support for Harvoni in this clinical setting.  In this patients case, Harvoni is medically indicated to prevent further progression of fibrosis due to hepatitis C infection and prevent potential complications of advanced liver disease in the long-term.  All told, Harvoni is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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: All 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.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee requested authorization and coverage of intensity modulated radiation therapy (IMRT) for the treatment of prostate cancer.  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 not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for electroconvulsive therapy (ECT) provided and inpatient hospitalization services provided when she received ECT for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that ECT is recognized as a safe, rapid and highly effective neuromodular intervention available for the treatment of severe affective illness, including both unilateral depression and bipolar disorder.  A typical index course of ECT consists of six to twelve treatments provided at a frequency of three treatments per week.  The intervention is endorsed by the American Psychiatric Association as a first-line treatment for depressive episodes.  However, this patients diagnosis was unclear as the progress notes listed psychotic disorder, not otherwise specified, and the illness burden was steeped in psychotic features.  ECT is not a first-line treatment for a formal thought disorder, and the presence of a severe affective episode was not established.  Additionally, critical documents to support the application of ECT were absent.  There was no specific evaluation or consultation for ECT.  Final Result: The reviewer determined that the services at issue were 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

A 57-year-old female enrollee requested authorization and coverage of radiofrequency ablation. The Health Plan denied the request indicating that the requested therapy is investigational for treatment of lung cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that reviewing the patients medical records, the requested speech therapy is clinically indicated to address her speech and language deficits. The patient has delays in receptive and expressive language of approximately one year behind her peers. A pivotal point with regard to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with language delays. At issue is the notion that plasticity in the developing brain still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to receptive and expressive speech delays. For these reasons, the requested therapy is medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 12-year-old male enrollee has requested emergency services for treatment of the enrollee's complaints of fever, dry cough and sore throat. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in these circumstances would believe the patient 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 developed a fever, cough, and sore throat. His father states in his appeal letter that he was concerned about H1N1 given the media attention surrounding that illness. It is documented in the record that the patient had not been vaccinated for influenza. Although this patient did not fit into any high risk category for influenza, it was reasonable for the parent to seek medical attention. However, this patient did not exhibit any acute symptoms of serious illness such as vomiting, trouble breathing, or irritability. He was over the age of five and had no underlying medical illness.  The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg for treatment of the enrollees hyperlipidemia.  Findings:  The physician reviewer found that the request for Repatha 140 mg has been established as medically necessary for treatment of the patients medical condition. Based on the records provided the patient has documented obstructive coronary disease, hyperlipidemia with LDL greater than 100 mg/dL and intolerance to both statin medication and ezetimibe. In this patient, the goal of LDL is less than 70 mg/dL. In this circumstance treatment with a PCSK9 inhibitor such as Repatha is medically necessary. Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol in spite of the highest tolerable statin and ezetimibe dose. This patient fits the latter criteria. In this setting PCSK9 inhibitors have been demonstrated in well controlled trials to be safe, effective and resulting in significantly improved cardiovascular outcomes. 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 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested hyperbaric oxygen therapy (HBOT) for the treatment of her head pain secondary to mastoid ablation. Findings:  Two physician reviewers found that hyperbaric oxygen therapy has been utilized in the treatment of many disease entities, including chronic infection, osteomyelitis and chronic pain syndromes. However, there is no supporting scientific evidence that a patient with pain that appears to be secondary to chronic severe mastoid disease and possible cerebritis, would benefit from such treatment or that such treatment would be more efficacious than any other available treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested Pro Air inhaler #4, Promethazine with codeine cough syrup #2 and Norco 10/325 #180 for treatment of her chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that there is inadequate documentation to support the medical necessity of the requested Pro-Air medication. The patient has non-malignant chronic pain syndrome, which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates may be adjunctive to this therapy with close monitoring by a certified pain management physician (Fishman). Ballantyne and Mao reported that, prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. Consistent with these findings, the requested Norco, Promethazine with Codeine, and Pro Air inhaler, are not supported as medically necessary for treatment of this patients medical condition.