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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orencia ClickJect Autoinjector 125 mg/mL. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. Findings:  The available medical records do not document failure of traditional disease modifying antirheumatic drugs (DMARDs) such as methotrexate, Arava, or sulfasalazine.  The patients provider noted that treatment with traditional DMARDs is prohibited and contraindicated in patients who have had gastric bypass surgery; however, review of the the scientific data reveals there is a lack of peer reviewed medical literature to show that DMARDs is contraindicated in patients who have a history of gastric bypass surgery. Additionally, methotrexate is available in an injectable form if absorption of medication appears to be an issue.  On the basis of the available peer reviewed evidence based literature, Orencia ClickJect Autoinjector 125 mg/mL has not been demonstrated as medically necessary for treatment of this patients medical condition. Final Result: The reviewer has determined that the requested medication is 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 internal medicine with sub-specialty certification in rheumatology 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 advanced lipoprotein testing (CPT 83695 and 82172). The records provided for review document that this patients low density lipoprotein (LDL) cholesterol was 187 mg/dL on routine lipid panel testing. Her provider recommended advanced lipoprotein testing. However, there is a lack of accepted clinical studies demonstrating that strategies to correct the residual risk identified by novel lipoprotein testing, such as the advanced lipoprotein analysis, will further reduce a patients cardiovascular risk. The peer-reviewed medical literature has not demonstrated that advanced lipoprotein testing adds significant information to data yielded from a standard fasting lipid panel. Given these findings, the advanced lipoprotein testing (CPT 83695 and 82172) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the advanced lipoprotein testing (CPT 83695 and 82172) 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: The patient has requested authorization and coverage for Acthar Gel. Findings: A study reports that repository corticotropin injection may be a safe and effective option for patients with refractory psoriatic arthritis who failed therapy with multiple previous treatments. The author notes that repository corticotropin injection may be used to bridge with another psoriatic arthritis therapy. In this case, the patient is being treated with the biologic medication Tremfya. Given that current medical literature supports the use of the requested medication as an adjunctive therapy in combination with a biologic medication to prevent exacerbation of the disease, the requested medication is medically indicated. Therefore, Acthar Gel 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 certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested a referral to an orthopedic specialist for an assessment of her hemangioma. Findings:  The physician reviewer found that the development of the MRI scan has led to the identification of many asymptomatic incidental hemangiomas of the spine (see Hiari and colleagues). Hemangiomas are benign tumors, involving about 10% of the world population, and generally remain asymptomatic throughout the entire life of the individual (see Bandiera and colleagues). Regular follow-up monitoring of asymptomatic hemangiomas is unnecessary unless pain or other problems develop at the appropriate level (see Fox and Onofrio). Only 1% of vertebral hemangiomas are symptomatic (see Murugan and colleagues). In this patients case, the submitted records do not document the presence of pain or other neurologic findings which would indicate the need for further evaluation of the patients hemangioma at this time. Therefore, the Health Plans denial of the request for a referral to an orthopedic specialist is medically appropriate.
Appeal type: Urgent Care
Decision: Upheld

A 49-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that an emergency room is necessary where there is a sudden onset of symptoms of such severity that a prudent layperson would believe their health to be in jeopardy without immediate medical attention. This patient did not experience the sudden onset of symptoms. Although she was experiencing pain, her pain had begun at least a week prior. She specifically denied any chest pain or other acute symptoms. She had previously been evaluated, diagnosed, and treated for the same condition. According to the documentation, this patients symptoms do not meet the definition of a medical emergency.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for colonoscopy. The provided documentation indicates that this patient underwent an evaluation with a colonoscopy in 2020. The joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that the interval for repeat screening colonoscopy depends on the findings at the baseline colonoscopy and subsequent colonoscopies (Gupta, et al.). Based on these guidelines, a repeat colonoscopy is not medically necessary for evaluation of this patient. The reports provided do not document incomplete polyp resection, inadequate preparation insufficient to find polyps, or other indications during prior colonoscopy or colonoscopies to support a modified screening schedule departing from guideline recommendations. Additionally, the applicable guidelines recommend colonoscopy every five years for patients with a family history of colorectal cancer unless other findings warrant colonoscopy sooner. The records do not document the presence of symptoms such as hematochezia or unintentional weight loss, which would require assessment with a colonoscopy. For these reasons, the requested colonoscopy is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested Livalo 2mg for treatment of her high cholesterol.  Findings:  The physician reviewer found that based on the records provided, the patient has significant cardiac risk in association with severe hyperlipidemia. Since the patient was unable to tolerate preferred formulary alternatives of simvastatin and atorvastatin, treatment with a non-preferred statin is reasonable, appropriate, and considered standard accepted practice in the medical community. In this circumstance treatment with a statin medication to lower LDL cholesterol below 130mg/dl is reasonable and conforms to aggressive guidelines. Medical necessity criteria for the use of 20mg of Livalo (pitavastatin) has been met, as there is documentation confirming that the cholesterol lowering medications have been tried and resulted in clinically relevant intolerance that would lead to non-adherence.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90/400 mg for eight weeks.Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated with Harvoni for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Upheld

The patient has requested authorization and coverage for inverted nipple surgery of the left breast. Researchers found that, inverted nipples are usually a congenital problem but may be related to scarring from breast-feeding or infection in the ducts or a previous breast surgery. Nipple inversion can cause functional problems such as irritation, rash, discomfort and may prevent the ability to breast-feed. There is no reported problem or documentation of a problem with irritation. The patient is of advanced maternal age and there is no reported inability to nurse or anticipated problems with nursing. Given these findings, the requested inverted nipple surgery of the breast is not medically necessary. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this patients case, an inverted nipple is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The patients inverted nipple is a normal variant present in 2% of women, which is of medical significance only when it causes a functional problem. The records do not document any functional problems related to the patients inverted nipple. Moreover, the requested surgery will not provide a more than minimal improvement in the patients appearance. All told, the requested inverted nipple surgery of the left breast is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) level of care services. Findings: The physician reviewer found that based on the available documentation, the PHP level of care services provided on the date of service in question forward were not and are not medically necessary for treatment of this patients medical condition. Due to the patients minimal behavioral health treatment history and his presentation, the American Academy of Child and Adolescent Psychiatry (AACAP) recommends treatment in a less restrictive setting than PHP. The patient could receive effective treatment on an intensive outpatient basis due to his lack of current self-harm behaviors, and lack of active suicidal or homicidal ideation. The supplied documentation does not indicate that he is having severe mood swings, or other severe psychiatric symptoms. In addition, the patients score on the child and adolescent level of care utilization system (CALOCUS), the patient is a candidate for treatment with intensive outpatient services. Thus, the requested PHP level of care provided from on the date of service in question forward were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were not and 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 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: Experimental/Investigational
Decision: Overturned

A 23-year-old female enrollee has requested reimbursement for the AlloMap molecular expression tests performed on three occassions for evaluation of the enrollee, who is status post two heart transplants. Findings:  Two physician reviewers found that the patient has a history of two prior heart transplants.  These transplants were performed approximately two decades apart.  The patient has been followed by her providers for possible signs of rejection.  She has requested reimbursement for AlloMap molecular expression tests performed on three separate dates.  AlloMap testing is intended to aid in the identification of rejection in stable heart transplant patients.  In order to monitor the heart muscle for cellular rejection, right ventricular biopsies are typically obtained at a decreasing frequency of intervals after transplantation.  These biopsies carry a risk of complications, including vascular complications and damage to the heart.  Per the International Society of Heart and Lung Transplantation guidelines, AlloMap testing can be used to rule out the presence of acute cellular rejection in appropriate low-risk patients between six months and five years following heart transplantation.   However, the U.S. Food and Drug Administration noted that the testing at issue may be indicated for patients who at least 55 days post heart transplantation.  Thus, some heart transplant centers use AlloMap molecular expression testing routinely beginning at 55 days post transplantation, and the use of AlloMap molecular expression testing during this time frame is medically acceptable.  In this patients case, AlloMap molecular expression testing performed on the second and third dates were likely to be of greater benefit than other tools for evaluating this patient, as these tests occurred greater than 55 days, and less than five years, post heart transplantation.  AlloMap molecular expression testing performed on the first date in question was not likely to be more effective than other methods of evaluating this patient, as this occurred more than 20 years following the initial heart transplantation.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested Rituxan for medical treatment of her multiple sclerosis. Findings:  Three physician reviewers found that this patient has a history consistent with aggressive multiple sclerosis, and she has tried and failed Avonex, Rebif, and Tysabri.  The current medical evidence has not established the superior efficacy of the requested medication in this clinical setting.  She has not been treated with Aubagio or Gilenya, two oral agents which are established disease modifying medications for multiple sclerosis, with known safety and efficacy.  Based upon the clinical documentation, Rituxan is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested six months of individual mental health therapy sessions for medical treatment of her depression and anxiety.   Findings:  The physician reviewer found that according to the current medical literature, behavioral interventions, not individual therapy is recommended in this clinical setting. All told, the medical records do not support the medical necessity of the requested six months of individual mental health therapy sessions for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested for Ativan for treatment of her multiple mental health conditions. Findings:  The physician reviewer found that Ativan is an appropriate medication for treatment of the patients psychiatric disorders. Ativan is indicated for anxiety disorder and can be used as an adjunct medication in bipolar type II disorder. Thus, the patient meets clinical indications for Ativan based on her psychiatric diagnoses. The continuation of Ativan in this setting is medically necessary and should be authorized.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 12-year-old male has requested coverage for past emergency services. Findings:  The physician reviewer found that the patient presented to the emergency room with a facial rash which was minimally itchy but not noted to be painful. The patient was afebrile, and the rest of his vital signs were normal. The rash was described by the treating physician as occurring in two patches on the right side of the face, being slightly erythematous, and having a papular component. It was not thought to be cellulitis or impetigo. The patient was given a prescription for an anti-fungal cream and discharged to follow-up with his primary care physician. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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 documentation does not demonstrate the presence of any signs or symptoms that would cause a prudent layperson to believe he or she was experiencing an emergency medical condition. There is no documentation of severe pain, high fever, or dysfunction of the eye or jaw associated with the patients rash. While the patients parent was concerned about the rash being infectious, this could have been addressed by consulting the patients primary care physician. A prudent layperson would not have thought this to be an emergency medical condition for which immediate medical attention was required.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. Findings:  The physician reviewer found that the requested service is not medically necessary for evaluation of the patients medical condition. According to the documentation submitted for review, radiographs demonstrate degenerative changes including facet arthropathy at L5-S1. A neurological examination indicated there were no fractures present or history of trauma, malignancy, or absent reflexes. The patient began physical therapy for treatment of lower back pain. Given that the patient has not completed a six-week trial of conservative management such as physical therapy, the request for MRI of the lumbar spine has not been established as medically necessary for evaluation of the patients back pain. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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.