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

The patient is a 21-year-old female with cystic fibrosis. The patients provider indicates the patient has benefited from use of the Vest Airway Clearance System (the Vest system) and has had only two hospitalizations while using the device. The patients provider also notes the patient has used both a Flutter device and chest physiotherapy (CPT) with minimal success. A hospital discharge summary from June 2004 states the patient was admitted for 48 hours of hemoptysis. The patient was discharged on intravenous antibiotics for cystic fibrosis exacerbation. The record also shows the patient had a baby in March 2004 and that she is the primary caregiver for her child. A request has been made for continued use of the Vest system. The Health Plan has determined that the requested equipment is not medically necessary for treatment of the patients cystic fibrosis.There are many studies to support the contention that enhancing mucous clearance in patients with bronchiectasis, (specifically cystic fibrosis) results in a benefit in disease control and symptoms. These include the use of chest physiotherapy, postural drainage, and mucolytics. The submitted literature reviewed the high frequency chest compression (HFCC) devices with other mucous clearance methods such as the Flutter device and chest physiotherapy. Overall, the methods appear to be equivalent in terms of secretion clearance. The patient is concurrently using various methods of secretion clearance including bronchodilators, inhaled recombinant DNase (Pulmozyme), and Flutter device. Secretion clearance is paramount in the management of cystic fibrosis as it prevents infections and improves symptoms. The patient is an adult who recently had a baby and is the primary caregiver for the child. She would greatly benefit from a method of self-administered secretion clearance. The submitted documentation indicates the patient has used the Vest system since 1999 and has had few hospitalizations and exacerbations. HFCC devices such as the Vest system are widely accepted and are standard therapy for patients with cystic fibrosis. Thus, continued use of the Vest system is medically appropriate and indicated for continued management of the patients cystic fibrosis.Based upon the information set forth above, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar artificial disc replacement surgery. Findings: There is a lack of evidence in current medical literature supporting the efficacy and long-term effects of multi-level lumbar artificial disc replacement in patient outcomes. A study notes that there is insufficient evidence to show that lumbar total disc replacement is superior to fusion surgery. Another study reported that while further advancement and studies are warranted to assess the long-term durability and sustainability of lumbar disc arthroplasty, it is an acceptable alternative within the surgical armamentarium for selected patients. In this case, the records document facet arthropathy and foraminal stenosis due to facet hypertrophy. Given the high rate of failure of artificial discs in this clinical setting, the requested services are not medically indicated. Therefore, lumbar artificial disc replacement surgery 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 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: Overturned

A fifty-six year-old male who has chronic hepatitis C, genotype 1a is requesting authorization of treatment with Infergen and ribavirin.  The patient was a non-responder to previous Pegintron and ribavirin therapy.   Reviewers Findings:  The reviewing physician found that Infergen has been approved by the FDA and is specifically indicated for the treatment of patients who have not responded to pegylated interferon therapy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested for a vacuum-assisted socket system (VASS) for treatment of his left leg, below-the-knee amputation. Findings:  The physician reviewer found that a VASS is designed not to have any specific weight-bearing area and which allows the patients weight to be uniformly distributed and thus helping to avoid skin breakdown and related complications. Patients with trans-tibial amputations who use a VASS benefit from the improved stump volume maintenance and reduced localized pressure which results in a more symmetrical gait. Board, et al. demonstrated that a VASS ensures a good fit through the day preventing irregular stump fluid balance. Patients using a VASS frequently experience less fatigue, discomfort, and have improved ambulation endurance. A VASS also improves vascularity due to the decreased localized pressure on the residual limb.
Appeal type: Medical Necessity
Decision: Overturned

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 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. The guidelines recommend that treatment-naive genotype 1 patients 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. For these reasons, 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: Urgent Care
Decision: Overturned

A 38-year-old male has requested coverage for emergency services provided.  Findings:  The physician reviewer found that the patient presented to the emergency department with complaint of recurring headaches. The patient had previously received treatment in the emergency department three days prior to this admission for a severe migraine and returned to the emergency department on the date at issue due to a recurrence of his migraine headache. The patient states that during his previous visit, he was instructed to return in three days for an MRI if he experienced additional migraines. The patient states he had additional migraine headaches and therefore returned to the emergency department as directed.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted evidence demonstrates that a prudent layperson would have sought immediate medical attention on the date of service in question. The patient presented previously with acute symptoms of headache, visual loss, and extremity numbness. The patient had been instructed to return to the ED on the date in question for an MRI if his symptoms persisted. The patient reports that he experienced additional migraine headaches and therefore returned to the emergency department as directed.  All told, a prudent layperson in these circumstances would have sought immediate medical attention on the date in question.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested authorization and coverage of a breast biopsy. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees ductal carcinoma of the breast.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.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested reimbursement for a right knee injection of Synvisc One (6mL) provided on the date in question and prospective authorization and coverage for future injections of Synvisc One (6mL) for treatment of the enrollees osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The effectiveness of viscosupplementation as part of the treatment of osteoarthritis of the knee is considered to be most suitable in patients with mild to moderate knee involvement, and in those for whom other approaches have failed or are contraindicated.  At this time, current medical studies have not concluded that one product has a greater efficacy than another.  In this patients case, there is documentation to support the diagnosis of osteoarthritis, and the description of the severity of the patients disease and the minimal effusion support the potential value of viscosupplementation as part of the treatment plan.  However, there is a lack of documentation demonstrating the need for a single injection, as opposed to a course of several injections.  All told, a right knee injection of Synvisc One (6mL) provided on the date in question and future injections of Synvisc One (6mL) were not and are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested laparoscopic Lap-Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  Although this patient is obese, severe obesity or morbid obesity is not documented.  Low body mass index bariatric surgery guidelines are not fully developed to allow for routine bariatric surgery without clear evidence of failure of maximal medical management or conservative efforts.  In this case, there are limited weight loss efforts documented.  The current medical evidence does not support the requested procedure in this clinical setting.  All told, the requested laparoscopic Lap-Band surgery is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested a Neuromonics evaluation and Neuromonics tinnitus treatment, utilizing the Oasis device for treatment of his tinnitus. Findings:  Three physician reviewers found that there is very little literature to support that outcomes of treatment for tinnitus with the Neuromonics method are positive. The studies that have been published to date are primary by the same authors. There has not yet been adequate investigation into this devices medical efficacy, especially in the long-term. As such, there is not enough evidence in the scientific literature to support the conclusion that the proposed device is superior to standard treatment (such as tinnitus masking devices). The submitted records do not document a trial of tinnitus masking devices by this patient. In sum, the patient is likely to derive greater benefit from further attempts at standard therapy than from Neuromonics therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient substance abuse treatment. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition.Findings: The requested services are not medically necessary based on the timeliness of the clinical documentation. Treatment referrals ordinarily progress in a step wise fashion from less to more restrictive settings. However, determining the level of care is a case specific, patient centered process, and the most appropriate entry point for an episode of care may in fact be a residential setting. The records demonstrated that this patient has severe addictive illness.  He has an early onset of use and family history of substance use. The patient has failed outpatient treatments.  The patients work environment, financial struggles, marital discord and depression are significant concerning factors as well.  However, the most recent clinical documentation was months ago.  The patients current clinical status, degree of psychosocial stress, extent of psychiatric and medical comorbidity, and standing in community based treatment and self-help efforts are unknown. Thus, at this time, inpatient substance abuse 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and Ribasphere RibaPak for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that according to the 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage. The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment. However, there is a lack of literature demonstrating superior safety or efficacy of Ribasphere RibaPak versus generic ribavirin. For these reasons, treatment with Sovaldi and ribavirin for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection, but treatment with Ribasphere RibaPak is not medically necessary. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld

A 31-year-old male enrollee has requested balloon sinuplasty for treatment of his chronic rhinosinusitis.  Findings:  Three physician reviewers found that the use of balloon instrumentation is increasing and outcome reports are mostly positive. The safety of this procedure and the ability to have it performed under local anesthetic are considered potential advantages of the procedure. However, there is not enough data to be able to conclude that outcomes with this technique are superior to those obtained through standard FESS. In addition, patient selection remains a concern as there are no agreed upon criteria regarding which patients are the best candidates for this surgical option. In addition, given this patients symptoms, physical findings, and CT results, it is advisable that he undergo further allergy evaluation. While surgical intervention of the sinuses may help with maxillary pressure, it is not likely that either balloon sinuplasty or standard FESS are likely to relieve nasal congestion, clear rhinitis, and postnasal drip in a patient with mucosal congestion and enlarged turbinates. All told, the requested procedure is not likely to provide the patient with an improved health outcome when compared with standard interventions.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested ongoing home speech therapy (2 times per week, 1 hour sessions) for treatment of her expressive aphasia.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue. This patient is improving clinically with home speech therapy. The patient requires continued speech therapy to treat her documented expressive aphasia. The submitted documentation demonstrates that she is restricted to the home environment by a medical diagnosis of anxiety. The patient is medicated for her anxiety but cannot leave the home environment without significant difficulty. Since the patients anxiety renders her homebound, she was and is an appropriate candidate for home speech therapy services. All told, the medical necessity of at home speech therapy at a frequency of two 1-hour sessions per week has been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested Leukine for treatment of Crohns disease.  Findings:  The physician reviewer found that Leukine is designated for the treatment of neutropenia. Due to neutropenia the patient cannot be treated with either immunosuppressive agents such as 6-MP, Imuran or Remicade. As such, it is prudent and appropriate to use Leukine in this setting, which allows for treatment of the patients Crohns disease and neutropenia with a single agent.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage of Symbicort inhaler for asthma with symptoms of shortness of breath, coughing spasms, and tightness in her throat. She also has environmental allergies for which she takes antihistamine medication and a nasal spray. The enrollee reports she has tried multiple inhalers, steroids, and antibiotics to control her asthma symptoms. Her allergist noted poorly controlled, moderate persistent asthma and a chronic cough as a result, and ordered Symbicort. Her primary care provider noted her asthma was stable with Symbicort and Albuterol, as needed. The enrollee returned with an upper respiratory infection and reported that she had tried to refill her Symbicort, but the pharmacist gave her Dulara, which she had failed. A new authorization for Symbicort was submitted and denied. A physician response to insurer inquiry regarding trial and failure of Breo, Advair and Dulera indicates enrollee advised to try formulary alternative but member is adamant about getting Symbicort. A review of the records shows no notations of contraindications, adverse events or potential drug interaction with formulary alternatives, such as Breo and Advair. There is no documentation of an inadequate treatment response after a trial of formulary alternatives. A review of the records indicates there is insufficient evidence of the enrollees failed trial of alternatives, such as Breo and Advair. . Researchers indicate that the combination of an inhaled corticosteroid and a long acting beta-2-agonist is considered a preferred therapy. They note combination therapy offers the best prevention of severe asthma exacerbation. The requested medication, Symbicort, is a combined inhaled corticosteroid and a long acting beta-2-agonist that has worked well for the enrollee. However, other available options include a combination inhaled corticosteroid, such as Advair. There are no  adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Symbicort over the preferred formulary medications for the treatment of this enrollees medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Pulmonology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.