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

A 38-year-old female enrollee has requested for a continuous glucose monitoring system and related supplies for treatment of her diabetes.  Findings:  The physician reviewer found that the equipment at issue was and is medically necessary for treatment of the patients medical condition because the patient is using this for pre-conceptive planning to maximize her control and minimize the risk of the fetus developing congenital/structural anomalies.
Appeal type: Urgent Care
Decision: Overturned

An enrollee has requested reimbursement for air ambulance transportation services. In this case, liver transplantation would prolong the patients life, and timely travel to the location where transplant surgery was to take place was required, otherwise the patient risked missing the time window and therefore opportunity for transplant. On the date of service, it was not certain that the patient would receive another opportunity to receive a donor liver, and the patient could very well die on the waitlist as hundreds do every year. Ground travel was not an option, given that travel of more than 1,300 miles was necessary. In addition, the time that would have been involved to arrange commercial air travel and navigate check-in and security screening, even if flight timing was optimal, would have been prohibitive, not to mention the likelihood of the frequent delays commonplace in commercial air travel. On the date of service, the only reliable, timely way to get the patient to his ultimately life-extending emergency transplant surgery was via air ambulance with coordination with ground services on the receiving end of the flight. Failure to provide liver transplantation during the narrow time window it was available for the patient would be reasonably likely to result in placing his health in serious jeopardy and would certainly directly impact his life-expectancy. Therefore, air ambulance services received on the date of service were provided for an emergency medical condition as defined in Health and Safety Code section 1317.1, subdivision (b).Final Result: The reviewer determined that the services at issue were provided for an emergency medical condition as defined in Health and Safety Code section 1317.1, subdivision (b). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HopeSeq HemeComplete genetic testing (concurrent analysis of HopeSeq HemeMutations, HopeSeq HemeFusions and HopeSeq Expressions). Findings:  The physician reviewer found that patients with myeloproliferative neoplasms can present with diverse clinical manifestations including splenomegaly, leukocytosis coming polycythemia, thrombocythemia, or eosinophilia. Reiter and Gotlib report that eosinopenia is a common feature of the family of diseases generated by dysregulated fusion tyrosine kinase (TK) genes. Chronic eosinophilia can be a primary myeloproliferative neoplasm due to clonal mutations in hematopoietic progenitor cells. An analysis of distinct  mutations may show whether the patient has a primary eosinophilia rather than a secondary eosinophilia caused by a separate disorder such as lymphoma. Furthermore, this type of testing is consistent with National Comprehensive Cancer Network (NCCN)  guidelines for myeloid/lymphoid neoplasms with eosinophilia and TK fusion genes. Therefore, HopeSeq HemeComplete genetic testing (concurrent analysis of HopeSeq HemeMutations, HopeSeq HemeFusions and HopeSeq Expressions) is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested HopeSeq HemeComplete genetic testing (concurrent analysis of HopeSeq HemeMutations, HopeSeq HemeFusions and HopeSeq Expressions) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested inpatient hospital services for medical treatment of his dyspnea with exertion/chest pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records note atypical chest discomfort after exercise and a negative initial evaluation.  In this case of a clinically stable patient with no objective evidence of ischemia, it would have been safe and effective to manage the patient at an observational level of care as opposed to a hospital admission.  Several studies have demonstrated the safety and efficacy of treating stable patients with chest discomfort in an observational setting as opposed to a hospital admission.  All told, inpatient hospital services were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested Orthovisc x3 injection series for treatment of his degenerative joint disease. Findings:  The physician reviewer found that the value of viscosupplementation in the treatment of degenerative joint disease of the knee is generally accepted (Strauss). With regard to the benefit of repeat courses of viscosupplementation, the evidence remains mixed. Some reports have indicated that repeat courses of viscosupplementation are safe and effective (Pagnano and Westrich). However, a study by Jergensen, et al. indicated that the efficacy of this treatment is questionable, as there was no noted reduction of pain, function or pharmacological consumption as measured at 3, 6, 9 and 12 months post treatment. In addition, an increased frequency of adverse events has been reported in patients receiving more than one course of treatment (Morton, et al.). As Johnson and colleagues reported, overall there is limited scientific evidence addressing the efficacy of multiple series of viscosupplementation. While there are current clinical studies in progress to determine the long-term efficacy and safety of repeat courses of viscosupplementation in patients with knee pain, at this time the benefits of this therapy has not been sufficiently established. For these reasons, the requested third series of Orthovisc x3 injections has not been shown to be medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for clonazepam 1 mg and the tapering off Norco. The U.S. Food and Drug Administration (FDA) has approved clonazepam for short-term relief of anxiety symptoms and for treatment of epileptic seizures. The FDA has not approved clonazepam or benzodiazepines for the treatment of CIDP, Guillain-Barre syndrome, or chronic pain. The 2016 Centers for Disease Control and Prevention (CDC) guidelines state that providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. In this case, the patient was on a combination of clonazepam and Norco for the treatment of CIDP, Guillain-Barre syndrome, and chronic pain. She had multiple inconsistent urine drug screens with the presence of THC and oxycodone. She received her last 30-day supply of Norco before she was discontinued from chronic opioid therapy. The combination of benzodiazepines and opioids present well-known risks to the patient. The patient was given a 30-day supply of opioids. It is unlikely that she will encounter any significant withdrawal symptoms, as it has been weeks since her last opioid dose. Based on the medical records, clonazepam 1 mg and the tapering off of Norco are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology with subspecialty certification in pain management 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

This patient is a 36-year-old man with metastatic malignant insulinoma with symptomatic hypoglycemia. He has requested authorization and coverage for Sandosatin LAR, a long-acting analog of the hormone somatostatin.His endocrinologist began him on a course of the short-acting Sandosatin when his cancer recurred postoperatively with good results. Both the short and long-term analogs have been shown over the past few years to be effective in a variety of pancreatic neuroendocrine tumors including metastatic insulinomas.The use of the somatotropin analogs such as Sandosatin and the longer acting Sandosatin LAR for the treatment of symptomatic gastroenteropancreatic neuroendocrine cancer is well established. These drugs can reduce symptoms of hypoglycemia and may even cause tumor shrinkage in otherwise incurable metastatic insulinomas. A comprehensive literature review published in January 2005 found more than 200 manuscripts published over the preceding one and half years on the use of somatotropin analogs in metastatic gut tumors, including insulinomas. The patient was shown to respond to the short-acting analog, Sandosatin. Both the article by Vinik and another series support the use of Sandosatin LAR in the treatment of gastroenteropancreatic neuroendocrine tumors. This preparation has been used for years in the community both for primary treatment of the severe hypoglycemia suffered by these patients as well as postoperatively if the tumor recurs as it has in this patient. The short-acting preparation has already proven to be effective in this particular patient. Sandosatin LAR is considered standard of care by endocrinologists in this clinical setting and should be authorized.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel (CPT J0800) 80 units subcutaneously twice weekly for six months. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of refractory nephrotic syndrome. While HP Acthar Gel is not recommended as a first-line therapy, data support its use in the therapy for patients who have failed to respond to or tolerate standard therapy. This patients records document that she has failed prior treatment with high-dose prednisone, mycophenolate, Lisinopril, losartan and labetalol for her diagnosis of primary focal segmental glomerulosclerosis. Therefore, the requested HP Acthar Gel (CPT J0800) 80 units subcutaneously twice weekly for six months 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 nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested  psychotherapy at a frequency of one to two times per week and neurofeedback therapy for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  With regards to the request for reimbursement for psychotherapy at a frequency of one to two times per week, the medical necessity has not been established.  The documentation does not include a recent clinical assessment, outcomes statement of past interventions or current treatment plan articulating patient-centric goals, quantifiable objectives, identified barriers to care and evidence-based modalities to address the issues unique to the case.  Additionally, the submitted documentation has not established the medical necessity of continued psychotherapy at a frequency of at least one time per week.  A comprehensive evaluation is needed to determine this patients current clinical needs.In this patients case, prior neurofeedback therapy was medically indicated.  Neurofeedback is not a first-line intervention, although there is sufficient evidence in the medical literature supporting neurofeedback as a reasonable intervention.  However, the submitted records fail to demonstrate the medical necessity of continued neurofeedback therapy, as a comprehensive evaluation is needed to determine the patients current clinical needs.  All told, a portion of the services at issue was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The conservator of a 19-year-old female enrollee has requested for eating disorder residential treatment level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the literature on the necessity for inpatient weight restoration is contradictory, as is the literature on the appropriate level of care for individuals with AN. According to Bulik and colleagues, `No studies address the optimal conditions under which a patient should be discharged from inpatient treatment and stepped down to less structured environments. This underscores the point that the patients symptoms must be managed appropriately prior to being stepped down to a lower level of care.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested reimbursement for psychiatric emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of a psychiatric emergency medical condition. According to the documentation submitted for review, the patient presented with a history of violent and aggressive episodes towards family, peers, and treatment providers. In the emergency room prior to inpatient admission, the patient required intramuscular chlorpromazine 25 mg due to escalating physical aggression. The patient displayed oppositional and aggressive behavior on the inpatient unit when the patient did not respond to redirection by staff. He was documented as engaging in aggressive behaviors including throwing, hitting, and kicking staff which required administration of chlorpromazine, as needed. Based on the patients clinical status, in addition to current medical literature, the inpatient level of care constituted emergency services for treatment of the patients behavioral health condition. For the reasons provided, the patient received psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the enrollee received psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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

The parent of a nine-year-old male has requested speech therapy services for treatment of his pervasive development disorder. Findings:  The physician reviewer found that the literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, 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 expressive and receptive speech delay. Therefore, speech therapy is medically appropriate and necessary for treatment of this patient who has a diagnosis of pervasive developmental disorder accompanied by speech and language delay with clear documentation of receptive and expressive language delay.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her chronic hepatitis C virus genotype 6.  Three physician reviewers found that data on treatment of hepatitis C virus genotype 6 are limited. The interferon-free option for genotype 6 infection is the fixed-dose combination of ledipasvir-sofosbuvir (Harvoni) given once daily for 12 weeks. In a study of 25 genotype 6 infected patients, this regimen resulted in a sustained virologic response rate of 96%. A less desirable alternative is a 12 week regimen of sofosbuvir plus peginterferon and weight-based ribavirin. This is also expected to be highly effective in the treatment-naive. The NEUTRINO trial, which evaluated this regimen in treatment-naive patients, included six genotype 6 patients, all of whom achieved sustained virologic response. Given that this option for genotype 6 infection includes interferon, which is associated with significant adverse effects, is not the preferred regimen. Consistent with these findings, the requested Harvoni is supported as medically necessary. Final Result: Three 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Spravato (esketamine) Nasal Solution.At issue in this case is whether Spravato (esketamine) Nasal Solution is medically necessary to treat the enrollees mental health or substance use disorder as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below? Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.According to Zheng and colleagues, intranasal esketamine has an ultra-rapid antidepressant effect in patients with major depressive disorder that lasts for at least 28 days. Moreover, Papakostas and colleagues state, Adjunctive intranasal esketamine for patients with major depressive disorder who are treatment-resistant or acutely suicidal appears to be an effective treatment strategy. In this case, the patient meets the criteria for treatment-resistant depression. This patient saw significant improvement in her symptoms while taking Spravato. It was not until there was a delay in her treatment that the patient saw some regression. Therefore, Spravato (esketamine) Nasal Solution is medically necessary for treatment of the patients medical condition. Treatment with Spravato (esketamine) Nasal Solution is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, Spravato (esketamine) Nasal Solution is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested Spravato (esketamine) Nasal Solution is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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 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: Upheld

A 36-year-old male enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees sexual dysfunction and urinary and bowel incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three of the 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 all three of the  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, the Health Plans denial has been upheld.