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

The patient has requested reimbursement for knee and debridement/shaving of articular cartilage (chondroplasty), same or separate compartment. Researchers performed a systematic review of the role for arthroscopic meniscectomy in knees with degenerative changes. The authors reported that two randomized controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. The authors concluded that patients with symptomatic meniscal tears and degenerative changes in the knee might benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. This patient sustained a left knee injury. He felt a left knee pop with immediate onset of medial joint line pain. His symptoms were reported as constant with functional limitations in ambulation. Conservative treatment included ice, activity modification, medications, and compression with inadequate symptom improvement. Clinical examination findings were consistent with reported imaging evidence of a medial meniscus tear. He underwent left knee arthroscopy with partial medial meniscectomy and medial femoral condyle chondroplasty. The operative report noted the presence of extensive complex tearing of the posterior horn of the medial meniscus and grade 2 medial femoral condyle chondromalacia. Current evidence based medical literature supports the surgery at issue for treatment of this patients acute injury, complex medial meniscus tear, and failed conservative treatment. Therefore, the knee surgery and debridement/shaving of articular cartilage (chondroplasty), same or separate compartment, was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 54-year-old female patient admitted for inpatient detoxification from synthetic opioids and alcohol, as well as depressive symptomology. According to the records, the primary focus of inpatient treatment was her depression. Alcohol and synthetic opioid addiction are apparently secondary to chronic pain and other life stressors. The patients inpatient care was certified through April 2006, and she was discharged in May 2006. The patient was discharged in May 2006. She has requested reimbursement for acute inpatient days from May 2006. The Health Plan has denied her request based upon a determination that acute inpatient psychiatric services were not medically necessary after the end of April 2006.In light of the treatment notes cited above, there is no justification for continued inpatient services for either psychiatric or substance abuse treatment after April 2006. The patient had no symptoms of acute withdrawal from any substance nor did she have any acute signs or symptoms of psychiatric relapse.  Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Oncotype DX testing. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Oncotype DX testing may be appropriate in select patients to guide the addition of combination chemotherapy to standard hormone therapy. Guidelines endorses the use of Oncotype DX testing in select patients with one to three positive nodes. This woman with one positive node and a lobular breast cancer which is generally felt to be less chemoresponsive. The medical evidence supports the requested services in this patients case. Thus, Oncotype DX testing is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 medical 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested continuous positive airway pressure (CPAP) machine for treatment of his sleep apnea.  Findings:  The physician reviewer found that typically, patients with clinically significant obstructive sleep apnea (OSA) have severe daytime hypersomnia reflected by an increased Epworth Sleepiness score and a decrease in the sleep latency. Since 1981, the medically necessary and generally accepted treatment of clinically significant OSA has been continuous positive airway pressure, CPAP.  In general, the medical necessity for CPAP is established in patients with an AHI of 15 or higher. This patients AHI was 13.2.  However, in individuals who have heart disease, a cerebral vascular accident (CVA), or hypertension, this criterion is changed to an AHI of 5 or greater. This is consistent with the Centers for Medicare and Medicaid Services (CMS) criteria and is the industry standard. It has been documented that patients with heart disease (this patient has coronary artery disease and congestive heart failure) with an AHI of 5 to 14 have a better health outcome if treated with CPAP. In addition, the patients O2 saturation decreased from 94% to 85% during the sleep study.  Thus, CPAP is medically necessary for this patient with an AHI of 13.2 and a history of coronary artery disease and congestive heart failure. Treating the patient with a vest to keep him from the supine sleep (treatment for positional sleep apnea) would not be effective in this patients case since the AHI was 11 on the left side and would also meet criteria for CPAP.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested six months of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (ASD). All told, treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. An article from Dawson and colleagues discusses a 5-year randomized and controlled study on 48 children with autism. The authors found significant improvements in IQ and adaptive behaviors using an Early Start Denver Model interaction based on developmental and ABA principles and with at least 25 hours of intervention services weekly. Similarly, Warren and colleagues reviewed 34 studies on early intervention in autism. The authors concluded that studies of Lovaas-based approaches, early intensive behavioral intervention variants, and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The requested duration of therapy for this three-year-old patient with autism is medically reasonable and appropriate. Given the patients documented deficits, it is medically necessary that he receive six months of ABA therapy beginning as of the date in question, as requested.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for treatment of the enrollees hepatitis C virus. 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage; in this case, there is imaging evidence of cirrhosis. Per the guidelines, Epclusa is recommended as a first-line regimen for treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed at this time, and the requested treatment with Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Upheld

A 72-year-old female enrollee has requested for Nexium for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for GERD continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. However, interpatient variability of the efficacy has been seen with PPIs. Milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant difference in their effects with regards to clinical or endoscopic endpoints or side effect profiles.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Finding:  Three physician reviewers found that treatment with Harvoni is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. In this case, the patient has advanced fibrosis and therefore, it is medically necessary to treat him with HCV therapy with Harvoni to potentially eradicate HCV infection and prevent further progression of advanced fibrosis to cirrhosis and its complications. Based on the documentation submitted for review and national guidelines Harvoni for 12 weeks is medically for treatment of the patients medical condition. Final Result: Three 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three 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 56-year-old female has requested the medication Byetta for the treatment of diabetes.  Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that while the patient was taking Byetta her medical conditions improved. All of these changes have been found to decrease the risk of both micro and macrovascular complications including blindness, renal failure and acute myocardial infarction. Given the failure of other therapies, it is medically appropriate for the patient to continue on Byetta for better diabetic control.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee requested authorization and coverage of the medication Xenical. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Urgent Care
Decision: Upheld

A 29-year-old male enrollee has requested services on an emergent basis. Findings:  The physician reviewer found that 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 clinical documentation demonstrates the patient had tonsillitis. He had been experiencing symptoms for two days. Although febrile, the patient was not in any distress. He described his symptoms as moderate. He was not experiencing any difficulty breathing or swallowing. The patients symptoms were not acute in onset and lacked the intensity that would cause a prudent layperson to believe his health was in jeopardy without immediate medical attention. As such, a prudent layperson would not have sought immediate medical attention on the date of service in question.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old male enrollee requested an insulin pump (E0784), continuous glucose monitor transmitter (A9277) and continuous glucose monitor sensors (A9276) for medical treatment of his type 1 diabetes.  Findings:  Three physician reviewers found that the requested equipment is likely to be of greater benefit than other available options.  This patient has type 1 diabetes and has been using an insulin pump.  He has been compliant with therapy, but continues to have low blood glucose levels and wide variations in his blood glucose levels.  There is sufficient medical evidence supporting the requested equipment in this clinical setting, as it will allow the patient to experience less glycemic excursions, with overall improved glycemic control.  Thus, the requested insulin pump (E0784), continuous glucose monitor transmitter (A9277) and continuous glucose monitor sensors (A9276) are likely to be superior over other alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hyaluronan derivative Euflexxa injections for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that current evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The literature also states that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. High quality scientific evidence does not appear to place a maximum amount of injections that an individual may receive for treatment of osteoarthritis of the knee. Moreover, hyaluronate treatment has been shown to be safe and effective. In this case, the patient has been diagnosed with advanced bilateral knee osteoarthritis. Functional limitations have been reported in activities of daily living. Clinical examination findings have been consistent with reported advanced arthritis. The patient underwent previous series of Euflexxa injections to both knees with significant pain reduction which was noted for at least six months. The patient was unable to take NSAIDs due to a kidney condition and conservative treatment including exercise have failed to provide sustained improvement. Final Result: The reviewer determined that the injections at issue were 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested authorization and coverage for Botox injections.Findings:  Three physician reviewers found Botox injections have been successfully used in adults and adolescents for the treatment of chronic migraine. In the pediatric age group, migraine headaches may be treated with off-label medications. The medical literature supports Botox injections for the treatment of pediatric patients with chronic migraine. In this patients case, she has been refractory to multiple medications. She has also experienced negative side effects from prior medications. There is support for Botox injections in this patients case. In sum, Botox injections are likely to be superior over other treatment options. 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 reviewers 1 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation medicine. 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

The parent of a 17-year-old male enrollee has requested chemical dependency residential treatment services for the treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that this patient presented with a significant chemical dependency problem which required treatment. Upon admission, the patient was using intravenous OxyContin and heroin, which are very dangerous substances. Of further concern in this case was the patients relationship with a family member who fostered the patients drug use, and thus, the home environment was not supportive. Furthermore, the evidence demonstrates the patient was benefitting from the services he received at the chemical dependency facility. He was motivated for treatment and beginning to experience improvement in mood. The patients provider indicates the patient was at high risk for relapse without the structure, support and education offered by a higher level of care.  All told, the services the patient received (which were residential treatment services rather than partial hospitalization services) were medically necessary for treatment of his condition. Given that the services provided were part of an integrated 30-day treatment program, the entire length of stay was medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Nutropin injection provided and prospective authorization and coverage for Nutropin injections. The Health Plan has denied this request indicating that the medication at issue was not and is not medically necessary for treatment of the enrollees idiopathic short stature. Findings: According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SDs) below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of the above criteria. The records indicate that this patients height is more than three SDs below the mean for his age and gender. His bone age is delayed, and his adult height prediction is under 63 inches, which is more than two SDs below his genetic target height. Although he passed provocative GH testing, he meets U. S. Food and Drug Administration criteria, which is the criteria set by the Pediatric Endocrine Society for a trial of GH therapy to improve height potential. Therefore, the Nutropin injections provided and the request for prospective authorization and coverage for Nutropin injections were and are medically necessary.Final Result: The reviewer determined that that the medication at issue was and 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 pediatrics with a sub-specialty certification in pediatric endocrinology 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.