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

This patient is a 62-year-old male with PSA of 4.4 on 12/16/2003. He underwent prostate biopsy on 1/23/2004 showing Gleason 3+3 adenocarcinoma of the prostate in the right side of the prostate, laterally in the mid prostate and base. The patient is seeking authorization for laparoscopic prostatectomy. The Health Plan has denied this request and approved the open radical prostatectomy for treatment of the patients condition.The patient is a 62-year-old male with a biopsy proven Gleason 3+3 stage T2a adenocarcinoma of the prostate, with a Partins table probability of 51 to 66% that the cancer is organ confined. The patient is requesting authorization for laparoscopic prostatectomy. Accepted appropriate alternative treatments for this patients condition include open radical retropubic prostatectomy. The open surgical approach is well established with good long-standing results in terms of survival and complications. The laparoscopic approach is newer with good short-term results in terms of survival and complications, but long-term results are not yet available. Complications rates of the laparoscopic approach appear to be comparable to the open approach; however, it is not yet known if long-term survival results will be comparable to the results of the open surgery. By recommending open radical retropubic prostatectomy, the Health Plan is offering an acceptable, appropriate and effective therapy for treatment of the patients medical condition. Laparoscopic prostatectomy has not been established as a more effective treatment for this patients condition Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 5-year-old female enrollee requested authorization and coverage of a referral to a specialist for the treatment of allergies and asthma.  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: Upheld

A 51-year-old male enrollee has requested Orthovisc injections for treatment of his advanced degenerative arthritis of the left ankle. Findings:  The physician reviewer found that the use of hyaluronic acid for viscosupplementation in the treatment of osteoarthritis has been generally accepted for use in the knee, however, there is limited published literature relating to its use in treating osteoarthritis in the ankle (Sun, et al.). Studies of larger size and longer duration are needed to evaluate this technique (McKee). Some preliminary studies have been favorable, but further evaluation is necessary (Kosia & Baumhauer). A paper by Migliore and colleagues found that the potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date. Thus, the evidence currently available is insufficient to establish the safety and efficacy of Orthovisc for arthritis of the ankle. As such, the requested medication is not a medically necessary therapy for treatment of the patients ankle pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV).  Findings: The physician reviewer found that while this patients records may not support advanced fibrosis, current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Also per the guidelines, 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.Afdhal and colleagues state, once-daily ledipasvir-sofosbuvir with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. In patients with viral loads less than 6million IU/mL, ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis (Kowdley) However, given that the patients viral load exceeds 6million IU/mL, a 12 week course of Harvoni is clinically indicated. Therefore, the requested Harvoni is medically necessary for treatment of the patients medical condition.   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-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 34-year-old female enrollee has requested emergency services for the treatment of her leg pain. Findings:  The physician reviewer found that the patient had an acute event that required an emergency room visit. Based upon the evidence in the record including the patients statements and the hospital staff this acute event was unforeseen. The patients objective examination by the emergency room staff revealed significant enough abdominal findings to warrant an admission and observation. The patient underwent imaging that localized the cause to a left ovarian cyst. The cyst was large enough to cause significant pain. The surgeons findings at laparoscopy confirm the presence of the cyst, and clear evidence of a rupture with some hemorrhage. This finding was very significant in that it is a significant cause of acute pain in women, which occasionally requires surgical intervention. Attempts at excision of the cyst were reasonable in that the type of cyst was unknown. Based upon this information, there was adequate medical justification to admit the patient and perform the surgery due to the severe nature of the pain and tenderness. A prudent layperson with an average knowledge of medicine with this patients symptoms would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested revision of bilateral mastopexy for treatment of her breast pain.  Findings:  The physician reviewer found that the submitted documentation does not include photographs or measurements to document breast ptosis that would require mastopexy. Mastopexy is not a treatment for breast pain. There is no documentation that the scars from previous breast surgery are symptomatic, so there is no justification for scar revision. Based upon the submitted records, there is no documentation that a condition which constitutes an abnormal structure of the body exists. There is no indication that the requested surgery would be performed to either improve function or create a normal appearance to the extent possible, or even minimally improve appearance. The expanded concept of medically necessary reconstructive surgery defined in California law is not met.  All told, the requested procedure is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollees parent has requested authorization and coverage for spinal surgery for placement of the vertebral body tethering (VBT). There are multiple studies showing the safety and benefit of VBT, with the potential to avoid fusion. The records provided for review document that this patients imaging demonstrated an apex right thoracic curve of 40 degrees and an apex of the left lumbar curve of 20 degrees after doffing the brace. Based on the current medical literature, the requested spinal surgery for placement of the VBT system 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Overturned

A 55-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  The physician reviewer found that with a BMI of 38 and the presence of significant co-morbidities (i.e., hypertension), the patient is an appropriate candidate for weight loss surgery based on generally accepted guidelines. The laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for clinically severe obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of 5-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of hypertension and sleep apnea compared to other restrictive procedures, with relatively low major complication rates. Thus, the requested procedure, sleeve gastrectomy, is an appropriate modality for the treatment of obesity in the well selected patient such as this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral dual x-ray absorptiometry (DXA) provided by Sutter Tracy Community Hospital. Cosman and colleagues note that in postmenopausal patients aged 50 and older, DXA measurements may be used to establish or confirm a diagnosis of osteoporosis, predict future fracture risk, and to monitor patients. The authors recommend that the DXA be performed in the lumbar spine (L1-L4), total proximal femur, or femoral neck when evaluating for osteoporosis. In this case, the submitted records do not demonstrate any extenuating circumstances for using peripheral DXA and there is a lack of evidence in current medical literature that peripheral DXA  is superior to a lumbar, spine. and hip DXA. Therefore, the peripheral dual x-ray absorptiometry (DXA) provided by Sutter Tracy Community Hospital was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the peripheral dual x-ray absorptiometry (DXA) provided by Sutter Tracy Community Hospital was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 rheumatology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electrical bone growth stimulator (HCPCS E0747). Clinical studies show variable safety and efficacy of electrical bone growth stimulation under different conditions and patient scenarios. Khalifeh and colleagues concluded that electrical bone growth stimulation presents a unique approach to accelerate healing and promote fusion success rates. Cook and colleagues found that the use of electromagnetic fields in bone healing have been studied, with most results showing improvement in healing of both bone and cartilage. Most supportive data are found in relation to the spine, femur, and tibia, but there is increasing evidence for its use in the foot and ankle for treatment of non-unions and as an adjunctive device in arthrodesis, particularly in high-risk populations. This patient presents status post left tibia and fibular fractures, as well as severe left foot skin traumatization and fractures. As of 6/17/20, the provider indicated that the patient had tenderness to palpation along the mid-shaft of the tibia along the fracture site. X-rays revealed some callus formation to the tibia and minimal callus formation noted at the fibula. Additional physical therapy was planned. The provider recommended a bone growth stimulator. However, there is no discussion of follow-up x-rays to confirm a diagnosis of fracture nonunion and document no signs of progressive healing. Moreover, there are no risk factors documented to support an indication for an electrical bone growth stimulator or detailed evidence of failed standard care. Therefore, the requested electrical bone growth stimulator (HCPCS E0747) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested electrical bone growth stimulator (HCPCS E0747) is not 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 device is 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 orthopedic surgery 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: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested reimbursement and prospective authorization and coverage for positron emission tomography (PET) with computed tomography (CT) attenuation already performed and in the future.  Findings:  Two physician reviewers found that the patient has a diagnosis of grade 3/4 gastric carcinoma. The patient has been treated with a combined course of radiation and chemotherapy. The patient had serial CEA levels that were at their lowest level of 5.3. The patients CEA was tested at 9.5. A positron emission tomography/computed tomography (PET/CT) scan was performed and then there was a follow-up for restaging. At issue in this case is whether the PET/CT scan done most recently and in the future is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, as the Health Plans stated in its denial letter that it considers this diagnostic procedure to be investigational. PET scanning has specifically been useful in gastric carcinoma when there is an established diagnosis for initial staging, evaluation of response to chemotherapy and need for restaging. This patient demonstrated a treatment response by his fall in CEA levels. However, the patient was not being treated and his CEA level began to rise. For this reason, the patients provider ordered the PET/CT for restaging. Based on this study, chemoembolization was recommended as the appropriate treatment option. As such, PET/CT was not ordered as a routine exam and treatment decisions were based on the results of the exam. Therefore, the PET/CT scanning requested for coverage was and is likely to be more beneficial than any available alternative to aid in the patients treatment planning.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of 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 (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 the guidelines, 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 regardless of fibrosis stage.  All told, Harvoni for 12 weeks 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

The parent of a seven-year-old male has requested  increased speech therapy for treatment of his autism. Findings:  The physician reviewer found that Myers and Johnson, et al. is frequently cited in the autistic literature as a definitive source of the evaluation and treatment of autistic children, and it is useful to quote from it in formulating a decision as to whether speech therapy is necessary in this case. According to the authors, [p]eople with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. The study by Turner, et al. is a controlled study comparing autistic children who did and did not receive speech therapy.  Those that did receive therapy had far greater communication skills than those that did not receive speech therapy. The report of the Speech-Language and Hearing Association, states that all autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. All told, it is medically necessary that this patient continue to receive speech therapy is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for Nerlynx 40mg tablets, as adjuvant treatment with trastuzumab therapy. The enrollee has stage IV breast cancer. The peer-reviewed medical literature reports Nerlynx has been used after trastuzumab; but not with trastuzumab. The safety and efficacy of the combination of these two therapies together is unknown. Researchers report adjuvant pertuzumab and neratinib (Nerlynx) modestly improves disease-free survival in early breast cancer, especially for those with a high risk of recurrence. A lack of complete response to preoperative chemotherapy and human epidermal growth factor receptor-2 targeted therapies is associated with worse outcomes. Future trials must focus on de-escalation of chemotherapy and biomarkers for further tailored therapy in early human epidermal growth factor receptor-2 positive breast cancer.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation oncology 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested a liver resection for the treatment of her metastatic cancer. Findings:  Three physician reviewers found that multiple reports have documented the rationale and potential gains of hepatic resection for metastatic breast cancer. In an excellent review of the literature, Friedrich, et. al. examines the evidence and concludes hepatic resection may play a role in selected patients. Additionally, Selzner, et. al. reported on 17 women treated over a span of 18 years who had undergone such resection in the absence of systemic disease otherwise, and noted a 22% long-term survival in carefully selected patients. A report by Vlastos, et. al. on 31 patients indicated the median survival with hepatic resection was over five years.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested the use of a continuous passive motion machine for treatment of his post left knee replacement. Findings:  The physician reviewer found that there is some evidence that the use of a continuous passive motion machine after total knee arthroplasty in the immediate postoperative period results in earlier increased motion and affords some benefit protection against deep vein thrombosis. However, there is a lack of evidence for any improvement with prolonged use after discharge. Per Bennett and colleagues, no significant difference has been shown with use after discharge. No differences in reported pain or range of motion over time have been demonstrated, per Leach and colleagues. Prolonged continuous passive motion machine use has not been found to benefit patients with insufficient range of motion at the time of discharge, per Lenssen and colleagues.  If flexion after surgery is unsatisfactory, vigorous rehabilitation appears useful, and if necessary, manipulation under anesthesia can be beneficial, but continuous passive motion has not been found to be effective.  In this patients case, use of a continuous passive motion machine was not and is not medically indicated.