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

A 39-year-old male enrollee has requested authorization and coverage for lumbar fusion surgery at the L5-S1 level for treatment of the enrollees low back pain. Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain. In the case of this patient, there is a lack of evidence of lumbar spinal deformity, instability or disc re-herniation. Thus, the patient does not meet the above mentioned indications for spinal fusion. Further, the American Pain Society has also developed evidence-based recommendations on the use of interventional surgeries for low back pain of any duration, which states that surgical benefits are often only moderate and appear to decrease over time (Chou, et al.). Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, as well as the lack of evidence that this patient meets clinical indications for surgical fusion, the requested procedure is not medically necessary for treatment of the patients low back pain. The Health Plans denial was appropriate in this case.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an eight-month-old male diagnosed with torticollis and plagiocephaly are requesting authorization of cranial orthotic therapy. Reviewers Findings:  The reviewing physician found that the record indicates the parents have attempted repositioning, but there is no evidence physical therapy has been attempted. Therefore, a two-month trial of physical therapy should occur before proceeding to cranial orthotics.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for removal of a fatty lump in the neck. Findings:  The physician reviewer found that Tte medical records document a mass of the right neck which is consistent with a probable lipoma. Although this may be a benign condition, there are several indications for removal. The mass is noted to be increasing in size, and the size is relatively large at 2 x 4 x 3 cm, especially considering the anatomic location of the upper neck above the level of the platysma.  Per the medical evidence, as the mass is both large and enlarging, surgical resection to confirm the diagnosis is medically reasonable. Additionally, the requested services are reconstructive in nature.  A lipoma or fatty mass is not a normal structure of the body.  This abnormal structure can be classified as a tumor.  Although there does not appear to be a functional impairment, the large size of the mass and its anatomic location of the upper neck contributes to an abnormal appearance.  In this patients case, the requested services are likely to create a normal appearance to the extent possible.  Given the size and its anatomic location, the requested services are likely to provide more than a minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the reviewer number two 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: Overturned

A 44-year-old female enrollee has requested a panniculectomy for treatment of her excessive skin.  Findings:  The physician reviewer found that based on the documentation provided in this case, the proposed surgery is not being performed solely to enhance the patients appearance. The patient complains of malodor, rashes, back pain and poor tolerance of exertion due to the pannus. The photographs clearly document that she has a severe pannus. The surgeon documents a significant abdominal pannus despite conservative measures consisting of weight loss and greater than six months treatment of intertrigo. This patient has functional issues related to the large overhanging tissue, which can be appropriately treated with a successful panniculectomy.  As further documented in the medical literature, common functional problems are described as when the abdominal panniculus causes disabling rashes, pain, physical limitation, back strain, and deformity. Symptoms are more marked the heavier the panniculus and often the dependent tissue creates problems of its own. Skin irritation under folds of redundant tissue is commonplace. (Manahan and Shermak and Leahy, et al.) This describes the patients condition. She has a large abdominal pannus that overhangs and overlaps the underlying skin. The patient and her physician describe functional problems as identified above and non-operative measures have been attempted without benefit. Given that the submitted medical documentation establishes a functional problem, the proposed procedure is not cosmetic and is medically necessary to appropriately treat this patients extensive skin redundancy.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested Xyrem for treatment of his narcolepsy.  Findings:  The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. This patient has not tried stimulant medications such as methylphenidate amphetamines or dextroamphetamine, which have been shown to be effective in the treatment of excessive daytime sleepiness associated with narcolepsy. The requirement that there be documented evidence of trial and failure of a stimulant medication prior to consideration of Xyrem is medically reasonable and consistent with the standard of care, as these stimulants have proven efficacy in this setting. Given that the patient has not tried and failed the stimulant medications listed above, the request for Xyrem is not medically necessary for treatment of the patients excessive daytime sleepiness associated with narcolepsy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee requested parathyroid planar imaging with single photon emission computed tomography/computed tomography (SPECT/CT) scanning for medical evaluation of the enrollees hyperparathyroidism.  Findings:  Three physician reviewers found that the literature shows the advantages of SPECT/CT in the evaluation of well selected patients for parathyroid adenomas since 20% of tumors are extra-parathyroid in nature. Thus, the merging of the pharmacologic agent with cross sectional anatomy is the most revealing technique available in the search for parathyroid adenomas. Further, the scientific data has demonstrated that SPECT with CT is superior to planar nuclear medicine imaging as well as SPECT without CT in this clinical setting. All told, the diagnostic procedure at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested coverage for proton beam radiation therapy for treatment of her presumed right cavernous sinus meningioma.  Findings:  Two physician reviewers found that the patient underwent an MRI scan of the brain due to a right sixth nerve palsy.  Findings were consistent with an enhancing mass in the right cavernous sinus extending to the Meckels cave and along the right anterior tentorial leaflet.  The findings were compatible with a meningioma.  The patient has requested coverage for proton beam radiation therapy.  In this patients case, proton beam radiation therapy is not likely to be more efficacious than other available treatment options. This patient has been diagnosed with a right cavernous sinus meningioma.  The current medical evidence does not demonstrate the superior efficacy of proton beam radiation therapy over conventional irradiation in this clinical situation.  Radiation dose for meningioma is in the range of 50 to 54 Gy, which is well within the tolerance of the brainstem.  The medical literature has not shown that proton beam radiation therapy is likely to be superior over intensity modulated radiation therapy in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cell-free fetal DNA-based prenatal testing for evaluation of the enrollees advanced maternal age. Findings:  The 3 physician reviewers found that the American College of Obstetricians and Gynecologists and the Society for MaternalFetal Medicine recommended cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy or trisomy, and women with positive first-trimester or second-trimester screening test results. Given that the patient is years old, the aneuploidy risk for this patient in this pregnancy warrants cell free DNA testing for aneuploidy. Therefore, the cell-free fetal DNA-based prenatal testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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 reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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 reimbursement for computed tomography (CT) scan. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has had continuing urologic difficulties.  However, per the submitted documentation, the patient had not been seen recently, and the medical records were from approximately one year prior.  Full-body CT scanning became popular several years ago as a patient directed means for preventive medicine.  This modality has been marketed directly to patients as a means for early detection of cancer, cardiac disease, and other abnormalities.  Several studies have been published concerning the possibility that the risks statistically outweighed the rewards.  Per the medical evidence, the increased risk of radiation induced cancers is a definite issue.  The current evidence does not support the services at issue in this clinical setting.  All told, the CT scan performed was not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Harvoni. The American Association for the Study of Liver Diseases (AASLD) and the Infectious  Diseases Society of America (IDSA) recommendations for the treatment of hepatitis C state, From a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus (HCV) eradication. Therefore, the panel continues to recommend treatment for all patients with chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. Given that this patient has a documented infection of hepatitis C, with a recent viral load of 993,000 IU/mL, the requested medication is medically indicated. Therefore, Harvoni 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 infectious disease 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: A male enrollee has requested authorization and coverage for lumbar spinal fusion of L5 and S1 discs for treatment of the enrollees back and radicular pain. Findings:  The physician reviewer found that the patients records do not support the medical necessity of the requested surgical intervention. The patient has no dermatomal/myotomal symptoms or findings compatible with a lumbar radiculopathy.  In addition, there is no documentation of neurogenic claudication. Except for two recent epidural steroid injections, there is no documentation of failed conservative management such as physical therapy, home exercise program, chiropractic care, pain management, or cognitive behavioral therapy. Moreover, there is no documentation of pain affecting his activities of daily living. According to current guidelines from the National Imaging Associates (NIA), for lumbar fusion require spondylolisthesis, spinal stenosis that is moderate-to-severe with functional impairment despite three months of conservative management; spondylolisthesis or instability or anticipated instability, fracture, or recurrent herniated nucleus pulposus with radiculopathy and instability; documentation and evaluation and management of addiction issues. Thus, the requested lumbar spinal fusion of L5 and S1 discs is not medically necessary for treatment of this patients back pain. Final Result: The reviewer determined that the requested surgery 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 neurological 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

A 63-year-old male enrollee has requested revisional total hip replacement surgery for treatment of his postoperative leg length discrepancy.  Findings:  The physician reviewer found that the patient does not require re-operation of the hip for a 1cm leg length discrepancy. A 1cm leg length discrepancy is quite normal as far as essential hip function is concerned. The patient should be able to easily compensate for this leg length discrepancy. There was one reference in the record to a leg length discrepancy of 2, but this was not confirmed by x-ray or physician examination. As such, revisional surgery is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees 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 (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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department with burning on urination and chills. He also felt as though his bladder was distended. His symptoms had not been relieved by prescription medication. The differential diagnoses in this patient included multiple infectious processes. The CT scan revealed an enlarged prostate, and he was treated for acute prostatitis, which may be associated with acute urinary retention. Such symptoms are consistent with an emergency medical condition. Therefore, the patient received emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the 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. The guidelines recommend that treatment naive genotype 1b patients should be treated with Zepatier. These guideline recommendations are based on high-quality clinical trials. Per the AASLD/IDSA guidelines, they cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C with Zepatier is supported as medically necessary for the treatment of this patients hepatitis C infection. 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.