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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Claravis 40 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients cystic acne vulgaris with hyperpigmentation. The submitted documentation supports the medical necessity of the requested medication. According to the records submitted for review, this patient has cystic acne. The patient has failed treatment with traditional therapies including topical retinoids, and adapalene. Isotretinoin is appropriate for patients with cystic acne. Claravis is approved by the Food and Drug Administration and is standard of care for this condition. According to the American Academy of Dermatology guidelines of care for the management of acne vulgaris, oral isotretinoin is appropriate for the treatment of moderate acne that is treatment-resistant. This patient has already tried and failed the formulary alternative, tretinoin, as well as adapalene, which is another topical in that class of drugs. Thus, Claravis 40 mg 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 dermatology 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 54-year-old female enrollee has requested for laparoscopic biliopancreatic diversion/duodenal switch for treatment of her morbid obesity.   Findings:  The physician reviewer found that Peer reviewed  articles clearly demonstrate superior weight loss and maintenance of weight loss over the long term with the duodenal switch as compared to other surgical procedures. The published data also demonstrates that the Roux-en-Y procedure results in as much, if not more, protein calorie malnutrition as the duodenal switch. The patients assertion that the duodenal switch is the most effective surgical weight loss alternative is well supported in the literature and this option should be made available to her.
Appeal type: Medical Necessity
Decision: Overturned

The parent of 1-year, 10-month-old male enrollee has requested speech therapy for treatment of the enrollees coloboma, heart defects, choanal atresia, retarded growth and development, genital abnormalities, and ear anomalies (CHARGE) syndrome.  Findings:  The physician reviewer found that based on the findings of Blake and colleagues, laryngeal, oropharyngeal or craniofacial anatomical abnormalities are not essential for abnormal language development to exist as seen in children with CHARGE syndrome. Thelin and Fussner suggest that although the patients developing brain has an underlying neurologic disease, the plasticity of the brain can still be utilized to improve overall neurologic health. Thus specific treatment, including speech therapies, 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 CHARGE syndrome and their co-morbidities including speech delay. Moreover, with specific regard to this patient with a diagnosis of CHARGE syndrome is the diagnosis, by definition, includes some degree of anatomic abnormality of the craniofacial structures. Thus, it is even more likely that this patient will benefit from the individualized sessions with a skilled speech therapist as requested.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested artificial disc replacement at the C5-6 level and spinal fusion at the C6-7 level for treatment of her cervical neuralgia and stenosis.  Findings:  Three physician reviewers found that despite the fact that artificial discs have been implanted for several years, there is currently insufficient data in the available peer-reviewed medical literature which adequately assesses the long-term performance of total disc replacement procedures. There is no evidence demonstrating that disc replacement reliably, reproducibly and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion and few adjacent segment degenerative problems. Although artificial disc replacement procedures have shown promise, they have also been associated with a high rate of re-operations and there is limited long-term follow-up data available. In this patients case, she has central canal stenosis at the C5-6 and foraminal stenosis on the left-hand side at the C6-7 level, for which the standard treatment would be a two level anterior cervical discectomy and fusion. Artificial disc replacement has not been shown to be superior to discectomy and fusion and has not been studied in patients with adjacent level disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni 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. The guidelines report that patients with cirrhosis are highest priority for therapy. Per guidelines, cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 24 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. AASLD guidelines cite data showing decreased survival with delayed treatment. The guidelines also recommend the use of Viekira Pak and ribavirin in certain genotype 1a patients, but do not recommend this combination in treatment-experienced patients with cirrhosis due to risk for severe decompensation of liver disease.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The 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:  The physician 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Botox injections for treatment of his moderate brow ptosis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the medical evidence, repeated Botox injections are not the standard treatment in this clinical setting.  The standard treatment for a visually significant brow ptosis is a brow lift surgery.  There is a lack of support for the requested services in this clinical setting.  All told, the requested Botox injections are not medically indicated 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 ophthalmology 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 is a 16-year-old male who has cerebral palsy with spastic quadriplegia. The patient lost the ability to transfer as he gained weight. A ceiling track lift system has been recommended. A Hoyer lift has been authorized by the Health Plan. At issue is whether the requested equipment is medically necessary for the patient.Upon review of the submitted information it does not appear that an in-home evaluation has been performed. As such, it has not been demonstrated that the requested ceiling track lift system is medically necessary at this time. An in-home evaluation is needed to determine if the Hoyer lift authorized by the Health Plan is medically appropriate. Doorways in the patients home should be measured to determine if the Hoyer lift will fit through the bathroom and bedroom doors. Also, measurements of the bathroom and bedroom should be taken to determine if the Hoyer lift can be turned once inside the room. Furthermore, the style of the patients tub should be evaluated to determine if a Hoyer lift can be placed on the tub or to the side of the tub to support safe and appropriate transfers. If the results of the in-home evaluation determine that a Hoyer lift cannot be used, the patients request for a ceiling track lift system should be reconsidered. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. However, the patient should receive an in-home evaluation to determine if the Hoyer lift offered by the Health Plan will allow safe and appropriate transfer of the patient. If it is determined the Hoyer lift will not provide safe and appropriate transfer of the patient the request for a ceiling track lift system should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg-100 mg for 24 weeks, in combination with ribavirin for treatment of the enrollees hepatitis C virus (HCV). Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines state that patients with liver transplant are highest priority for treatment. In genotype 3 patients who have had a liver transplant, therapy is recommended with Sovaldi, Daklinza, and ribavirin for 12 weeks or Sovaldi and Daklinza for 24 weeks. This is based on the ALLY-1 study, which showed a high cure rate in liver transplant patients, and other studies showing high cure rates.  However, the guidelines also state that Epclusa is never recommended in liver transplant patients, stating that based on the lack of real-world experience of the pharmacokinetics of sofosbuvir/velpatasvir in liver-transplant recipients and because alternatives with similar projected efficacy are available for which interactions with immunosuppression agents have been reported, we do not recommend the use of velpatasvir in transplant recipients at this time. Final Result: The reviewer determined that the requested medication regimen 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 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

A 30year-old female enrollee requested authorization and coverage for orthognathic surgery.  The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees maxillary hyperplasia.One oral surgeon reviewer performed a medical necessity Independent Medical Review.  The reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male has requested a pediatric otolaryngologist (ENT) specialist to perform his tonsillectomy and adenoidectomy.  Findings:  The physician reviewer found that Baugh and colleagues evaluated various findings in their clinical practice guideline based on the available peer-reviewed medical literature. As discussed, providers should recommend watchful waiting for recurrent throat infections if there have been fewer than seven episodes in the past year, fewer than five episodes per year in the past two years, or fewer than three episodes per year in the past three years. Further, the guidelines suggest that providers may recommend a tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year, or at least five episodes per year for the past two years with documentation for each episode of sore throat and one or more of the following: temperature greater than 38.3C; cervical adenopathy; tonsillar exudate; or positive test for group A beta hemolytic streptococcus (GABHS). Although this patient has been documented to have episodes of recurrent tonsillitis, there was only mention of four episodes within the past year without any mention of other subjective signs including fever, cervical adenopathy or tonsillar exudate or positive test for GABHS. Consequently, the patient does not meet the guidelines in the consensus statement. It is well established that pediatric sleep disordered breathing improves in the majority of cases after tonsillectomy and adenoidectomy surgery. Currently, children with symptoms of sleep disordered breathing are recommended to undergo polysomnography as a means of determining their clinical status. In this specific case, the parents reported abnormal sleep patterns but there was no mention of a polysomnogram. The documentation provided suggests that the patient was seen by two different participating in-plan otolaryngologists. The initial provider reported that he did not believe that the patient was a candidate for surgery at the initial visit and that the second provider suggested further monitoring and possible consideration of surgery. The patients tonsil size was described by both providers as about 2+-3+, but no crowding of the posterior oral cavity was seen. Subsequently, a non-plan provider recommended consideration of tonsillectomy and adenoidectomy for improvement of the patients condition. However, the Health Plan indicated there are competent plan board certified otolaryngologists who routinely perform tonsillectomy and adenoidectomy in uncomplicated pediatric patients. Reviewing the medical status of the patient in this case, there is no documentation of any complicated health issues that would require the services of a fellowship trained pediatric otolaryngologist. Tonsillectomy and adenoidectomy is a routine surgical intervention performed by most otolaryngologists. As this patient presents no other potential health related symptoms, routine tonsillectomy and adenoidectomy can be safely and adequately performed by the plan providers trained for this procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation of a thyroid nodule. This patient presents with a thyroid nodule that has demonstrated benign pathology on two fine needle aspirations. Thyroid nodules are a frequent finding on physical examination and on unrelated radiographic studies. Although most thyroid nodules are benign, current data suggests that approximately 10-15% of thyroid nodules are malignant (Pemayun, et al.). Benign thyroid nodules have the potential for malignant transformation and may cause compressive symptoms such as dyspnea and hoarseness. In this clinical setting, these nodules may require treatment (Chen, et al.). Thermal ablation using radiofrequency is a minimally invasive modality employed as an alternative to surgery in patients with benign thyroid nodules and recurrent thyroid cancers (Kim, et al.). Radiofrequency ablation may reduce the size of thyroid nodules and can lead to improvement in pressure symptoms and overall patient satisfaction (Guang, et al.). For these reasons, the requested radiofrequency ablation of a thyroid nodule is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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:  The enrollee is requesting authorization and coverage for Canasa. The enrollee has diagnoses of ulcerative colitis and ulcerative proctitis. The enrollees symptoms include rectal bleeding, left lower quadrant abdominal pain, and bloating. The provider prescribed Canasa (mesalamine) suppositories. A colonoscopy report showed internal hemorrhoids. The enrollees medications include balsalazide, oral and rectal mesalamine, Cortenema, and sulfasalazine. A progress note recommendeded the continuation of Canasa as the primary treatment for the enrollees ulcerative proctitis. A professional guideline strongly recommends Canasa (mesalamine) for ulcerative proctitis based on high-quality evidence.  Furthermore, a governmental body lists ulcerative proctitis as the indication for the use of Canasa. The professional guideline also states that, in those with ulcerative proctitis, rectal 5-aminosalocylate therapies compounds, such as Canasa, should be used for maintenance of remission. Since this enrollee has ulcerative proctitis, treatment with rectal topical mesalamine is consistent with the guidelines.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a sixteen-year-old female enrollee has for continued eating disorder residential treatment for treatment of the enrollees bulimia nervosa. Findings:  The physician reviewer found that the medical records document that the patient is still quite fragile emotionally and is not stable enough to be treated at a lower level of care. The patient has failed outpatient treatment, intensive outpatient treatment and partial hospital and residential treatment in the past. She has tried multiple medications and therapy. The medical documentation demonstrates that the patient continues to need ongoing stabilization at the residential treatment facility.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  This modality has been demonstrated to be particularly of benefit for patients with dense breast tissue.  Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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: Urgent Care
Decision: Overturned

A 23-year-old female enrollee has requested reimbursement for urgent care services.   Findings:  The physician reviewer found that the patient presented for urgent care due to a history of productive cough, headache, runny nose, scratchy throat and phlegm for four days.  She complained of having felt feverish.  Her brother was also ill for a period of time. The patients symptoms were unresponsive to over the counter medications. Her vital signs were normal. A letter from the patient and her parent indicated that the patients primary care physician did not have an appointment available for several weeks. Physical examination on the date in question was significant for erythema of the pharynx. The patient was diagnosed with an acute respiratory infection and was discharged on antibiotics and an antitussive medication. The patient has requested reimbursement for the urgent care services provided on the date in question, which the Health Plan has denied on the basis that the services not required on an emergent basis. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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 demonstrates that the patient was experiencing a constellation of symptoms at the time she presented which were consistent with a potential threat of serious deterioration of her health. Based upon the patients presentation, the differential diagnosis included meningitis, pneumonia, acute bronchitis, acute epiglottitis, acute pharyngitis, and other infectious disorders. Thus, the patients symptoms met prudent layperson criteria for emergent care, especially given reports that the patient would not be able to see her primary care physician in the near future. A prudent layperson in the patients circumstances would reasonably expect the absence of immediate medical attention to jeopardize their health.