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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. A report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. Moreover, post-hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have a viral load of less than 6,000,000 IU/mL can be treated with an eight week course instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines. 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 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 is a male who has requested acupuncture treatments for the treatment of cervical spondylosis. The Health Plan has denied this request indicating that the treatments are not medically necessary for treatment of the patients cervical spondylosis. At issue in this case is whether the requested acupuncture treatments are medically necessary to treat the patients medical condition. The patient has had sufficient acupuncture treatment with previous sessions. He has not made any increased or sustained improvement after the previous acupuncture treatment, per the records. There is no indication that he is expected to make further sustained improvement through more acupuncture treatment. Acupuncture is an effective short-term treatment for patients with chronic neck pain. However, there is limited evidence on the long-term effectiveness in this clinical setting. Additionally, studies show that acupuncture is not more clinically significant than sham-acupuncture or placebo for neck pain. Moreover, there is no evidence that the patient has tried or has been referred for proper medical management for his pain with treatments such as physical therapy, pain management, or cortisone injections. Therefore, the acupuncture treatments are not medically necessary.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 chiropractic and oriental 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: Upheld

A 44-year-old male enrollee has requested continued chiropractic visits for treatment of his low back pain.  Findings:  The physician reviewer found that systematic reviews of current literature suggest that spinal manipulative therapy is likely less effective than previously suggested. In addition, there is no scientific data supporting spinal manipulative therapy as superior to other therapies for treatment of back pain. While combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute low-back pain, current evidence neither supports nor refutes that such interventions provide a clinically meaningful difference for pain or disability in people with low-back pain when compared to other interventions.Per the documentation, the patient presented with low back pain and received chiropractic treatment including spinal manipulation during the time periods. The progress notes indicate that the patient had some improvement with these therapies. However, there is no specific documentation describing the patients range of motion, strength or pain scale. Further, the patient has already been instructed in a HEP, which should adequately address her chronic condition. For these reasons, the requested chiropractic treatment has not been established as medically necessary for treatment of this patients back pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of his medical condition.  Findings:  The physician reviewer found that the question of timing and necessity as to obtaining an MRI of the knee in the clinical setting of knee pain is critical in determining the appropriateness of the MRI.  Medical literature and evidenced based studies indicate that an MRI is the most optimal means to evaluate an internal derangement; plain x-rays are of only limited value; but these medical studies show that an MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films. (Miller) As noted in a paper by McCarty and colleagues, An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment. Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms. Patients with persistent or recurrent unexplained pain after the trial period of conservative treatment may require MRI and may require referral to an orthopedist as a next step in the evaluation.  However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. (Miller). In this patients case, the submitted records do not show that the patient has a fracture. Whether or not the patient has a degenerative change has limited bearing to the issue of obtaining an MRI. Medical studies support obtaining baseline plain x-rays in the clinical setting experienced by the patient. Thus, obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery. This incidence of abnormal MRI findings in asymptomatic individuals was established by Boden and Davis, The high incidence of abnormal MRI findings in asymptomatic subjects underscores the danger of relying on a diagnostic test without careful correlation with clinical signs and symptoms. Medical studies support obtaining an MRI if it will change the course of treatment. With this particular patient, his physical examination did not support a meniscal tear or a ligamentous injury or tear. In sum, an MRI for the evaluation of this patients medical condition is not medically necessary.  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. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee has requested for Botox injections for treatment of her headaches. Findings:  Two physician reviewers found that Botox injections are not yet considered standard treatment for migraine or chronic daily headache. In this case, there is a likelihood of medication-overuse headache and Botox injections would not be expected to improve the patients symptoms.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Rituxan infusions for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The provided medical records do not indicate any information regarding the status of multiple sclerosis, symptoms, impact, attack frequency, or prior medication trials.  There is mixed data regarding the effectiveness of Rituxan.  There is a lack of justification in the submitted records to use Rituxan compared to proven, multiple sclerosis disease modification therapies.  All told, the requested Rituxan infusions are not medically indicated for the treatment of this patient.  Final Result: The reviewer 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 neurology 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 44-year-old female has requested hearing aids for treatment of mild to severe sensorineural hearing loss.  Findings:  The physician reviewer found that based on the results of the hearing evaluation performed, the patient was diagnosed with sensorineural hearing loss in the high frequencies. However, the patients speech reception threshold was found to be within normal limits at 20 dB in the right ear, 25 dB in the left ear, with excellent discrimination scores at 86% in the right ear, 90% in the left ear. In these clinical circumstances, the patient does not meet medical necessity criteria for use of hearing aids for this specific type of hearing impairment. Most of the patients hearing loss is in the high frequencies above the speech range of 2000 Hz. Standard occupational noise exposure may induce hearing impairment. Consideration of hearing aid use is usually recommended for patients who have average reduction of hearing at 250, 500, 1000, 1500 Hz. These levels are not documented in this patients case. Additionally, there is no evidence of any chronic noise exposure in any employment situation for this patient. Although this patient reports she is unable to understand words properly in her work environment, there is no evidence of any medical reason that would document the need of hearing aids in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested participation in a clinical trial for cardiac catheterization for placement of a Cheatham Platinum (CP) stent in the aorta for the treatment of her coarctation of the aorta. Findings:  Two physician reviewers found that this patient is an adult with a discrete aortic coarctation distal to and not involving the left subclavian artery. The anatomy of the coarctation described is suitable to a percutaneous repair (discrete and not involving branch vessels). Further, percutaneous stenting with a stent has the appeal of involving less risk when compared to open surgical repair. Stents provide support to help prevent recoil of the dilated segment and when used for coarctation is designed to provide a framework for endothelial cell growth and perhaps reduce the complication of aneurysm formation. Therefore, in older adolescents and adults with suitable anatomy, cardiac catheterization for placement of a stent is a reasonable and appropriate alternative to open surgical repair of aortic coarctation. The CP stent specifically is not yet FDA approved for this indication but there is preliminary data that suggests superiority of this stent over alternative stents. In addition, the patient is to become part of a clinical trial for study of the CP stent and is therefore going to be followed closely by the providers recommending the procedure with appropriate follow-up and monitoring of outcome. Thus, the proposed clinical trial represents a better alternative for this patient than surgical repair or the use of other available stents. All told, aortic stenting has become an accepted alternative treatment in the medical community and would be superior over surgery for treatment of this patients medical condition. Furthermore, there is adequate evidence to support the benefits of the CP stent to warrant the patients participation in the proposed clinical trial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing CPT code 83698 and CPT codes 82172, 83695, 83701, and 83701-59 performed on a separate date of service. Findings:  The physician reviewers found that in this circumstance, prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. As such, CPT code 83698 performed and CPT codes 82172, 836695, 83701, and 83701-59 performed on separate date of service were not likely to be more effective than any available standard therapy in evaluating this patients medical condition. Final Result: 2 of 3 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: All three physician reviewers are board certified in internal medicine with sub-specialty 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: Urgent Care
Decision: Upheld

A 46-year-old male has requested coverage for emergency services.   Findings:  The physician reviewer found that the patient presented to the emergency department for evaluation of a dry cough for two weeks that was not improving. A medical screening exam was performed which revealed that he was afebrile with a normal respiratory rate, heart rate, and pulse oximetry on room air. Testing was performed to include an EKG, lab tests and a chest x-ray, but the patient left the emergency department prior to being seen by the physician on duty. Subsequently, he went to an Extended Hours Clinic and was seen by a physician assistant. Again, the patient was noted to be afebrile with a normal pulse, respiratory rate and pulse oximetry. Pain was not a presenting complaint, and no pain level was documented. The patient reported he had a dry cough for four weeks that was not improving, and felt short of breath. A history of asthma was noted. The physical examination was noted to be normal including that he was in no apparent distress, and the results of the studies obtained a few hours earlier at the emergency department were reviewed. The EKG and labs tests were unremarkable, but the chest x-ray showed lingular atelectasis versus an infiltrate compatible with pneumonia. The patient was diagnosed with pneumonia and cough and discharged from the clinic with prescriptions for Levaquin, Robitussin, and Tessalon Perles. He was instructed to follow-up with his primary care provider in one to two days.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date at issue. 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 evidence demonstrates that the patient had a dry cough for approximately two to four weeks. It was not associated with fever or chest pain, and the associated shortness of breath was not documented to be severe. The patients temperature, respiratory rate, and pulse oximetry were normal, and the patient was noted to be in no apparent distress. While the patient was diagnosed with pneumonia and did require medical attention, the submitted documentation does not demonstrate he was experiencing acute symptoms that required immediate attention. The fact that the patient left the emergency department without being seen by a physician is not consistent with the actions of an individual who believed he or she was experiencing a medical emergency. All told, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention in an emergency department.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Trulicity Pen injections for treatment of the enrollees diabetes mellitus. Findings:  The physician reviewer found that Trulicity is a member of the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss and low incidence of hypoglycemia. While Trulicity, and other members of this class of medications, may be an effective treatment option, metformin is considered a proven first-line treatment for type 2 diabetes. The patient states that she does not want to take metformin because of her history of primary biliary cirrhosis. However, following a thorough literature review, there was a lack of evidence that metformin is associated with worsening liver function in patients with primary biliary cirrhosis. Since the patient has not demonstrated an adequate trial of formulary alternative metformin, the requested Trulicity Pen injections are not supported as medically necessary. Final Result: The reviewer 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 endocrinology, diabetes, 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 parent of an enrollee has requested one-on-one applied behavioral analysis (ABA) services for treatment of the enrollees autism.  Findings: The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. Mohammadzaheri and colleagues noted that ABA is helpful for school children with autism spectrum disorders for aggressive, disruptive and tantrum behaviors. In this case, the patient presents with maladaptive behaviors that include aggression, tantrum and self-injurious behaviors. Given the patients elevated safety issues, aggression and self-injury, a reduction in ABA hours is not indicated for this patient. Therefore, the ABA providers recommendation of the continuation of 40 hours per week of one-on-one ABA services is medically necessary for treatment of the patients autism spectrum disorder.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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 56-year-old female enrollee has requested for the Gambro Theralite High Cut-Off Technology dialysis device for treatment of her renal failure requiring dialysis.  Findings:  Two physician reviewers found that the Gambro Theralite High Cut-Off Technology dialysis device was specifically approved for this patient and may help with the immediate removal of the light chains which is essential to decrease permanent kidney damage. All told, there is adequate evidence to support the contention that the proposed device is likely to be more efficacious for this patient than any other standard therapy.