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

A 36-year-old male enrollee has requested the morrow procedure (septal myectomy) for treatment of his obstructive hypertrophic cardiomyopathy.  Findings:  The physician reviewer found that although hypertrophic obstructive cardiomyopathy may be initially treated with medical therapy, the current indication for surgery includes symptoms unrelieved by intensive medical treatment in a patient with a ventricular outflow gradient of at least 50 mmHg. This patients echocardiogram while on medical therapy demonstrates a peak gradient of 55 mmHg with mild-to-moderate mitral regurgitation. However, the patients cardiac catheterization report documents a peak gradient of greater than 100 mmHg. Given these findings, the requested morrow procedure (septal myectomy) is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested authorization and coverage for removal of a growth on his finger for treatment of his neurofibroma. Findings:  The physician reviewer found that excision of the patients neurofibroma is not medically indicated because it is benign, is asymptomatic and does not interfere with normal functioning. A 5 x 5 mm nodule is not deforming.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested for treatment by a podiatrist every four (4) weeks treatment of his foot condition. Findings:  The physician reviewer found that the documentation provided does not demonstrate the presence of a complex condition that requires monthly follow-up. The services rendered to this patient are primarily focused on basic care of his lesion. There are multiple treatment alternatives available for this condition including topical agents, which the patients provider has apparently initiated. The patients response to treatment can be appropriately monitored at eight week intervals. There is no evidence the patients condition has deteriorated during the period he has received podiatry visits at eight-week intervals. All told, the submitted documentation does not establish the need for consultation with a podiatrist more frequently than at eight week intervals.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the left knee. Findings:  The physician reviewer found that  records provided for review document that this patient presents with a history of osteoarthritis of the left knee with associated chronic pain. She has failed treatment with arthroscopic surgery, and corticosteroid injections. The patient experienced excellent results from viscosupplementation with Synvisc One in the past. The provider has recommended a repeat Synvisc One injection for the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Therefore, the requested Synvisc One injection in the left knee 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. In a systematic review of meta-analyses, researchers conducted a systematic review of overlapping meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. In addition, researchers noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. This patient reported consistent relief with hyaluronic acid injections. Given this support, the requested bilateral Synvisc One injections are medically necessary for treatment of this patients bilateral knee osteoarthritis. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation for treatment of the enrollees degenerative disc disease and facet arthropathy. Findings: The physician reviewer found that the records provided for review document that this patient has a history of cervical degenerative disc disease and spondylosis. The patient previously underwent cervical facet radiofrequency lesioning in 2015 with greater than 50% pain relief for seven months. Currently, the patients pain is not responsive to conservative measures including a medication regimen consisting of high dose opioids. In the medical literature, Cohen and colleagues found that Radiofrequency denervation provides some benefit for up to a year in approximately 60% of individuals. Since this patient previously responded well to radiofrequency lesioning, the requested radiofrequency ablation is supported as medically necessary for treatment of her medical condition.Final Result: The reviewer determined that requested service 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 anesthesiology with sub-specialty certification in pain 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services provided on 3/19/16.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 urgent care services provided on 3/19/16 were not necessary for treatment of an emergency medical condition. In this case, the patient presented with the gradual onset of sore throat over two days. She was not experiencing difficulty breathing or swallowing. The patient was afebrile and in no acute distress. The patients symptoms were not sudden in onset or severe. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. 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: The patient has requested authorization and coverage for Humira 80 mg weekly. The U.S. Food and Drug Administration (FDA) approves the use of Humira (generic name adalimumab) for the treatment of moderate to severe hidradenitis suppurativa. For patients with hidradenitis suppurativa who did not respond sufficiently, or in patients with progressive response loss to an adalimumab dose of 40 mg weekly, Zouboulis and colleagues reported enhanced levels of effectiveness with adalimumab dose intensification to 80 mg weekly. Sanchez Martinez and colleagues found improved efficacy with adalimumab dose intensification to 80 mg weekly, with minor adverse effects such as mild infections or injection-site reactions. In this case, the patient has a diagnosis of severe hidradenitis suppurativa. She has tried and failed antibiotics, isotretinoin, and biologic therapies including Humira at standard dosing, Stelara, and infliximab. In this clinical setting, given that the patient has failed numerous therapies and as current medical literature supports the safety and efficacy of Humira 80 mg weekly, the requested medication regimen is medically indicated. Therefore, Humira 80 mg weekly 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 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: Upheld

A 33-year-old female enrollee has requested home uterine monitoring and a subcutaneous terbutaline infusion pump for the treatment of her preterm labor. Findings:  The physician reviewer found that the use of subcutaneous terbutaline as maintenance therapy for prevention of premature labor is extremely controversial. At present there is no firm evidence to support its use. The long-term or maintenance use of -mimetic drugs has been championed by clinicians who advocate detection and suppression of contractions to prevent preterm labor. Protocols for the continuous subcutaneous infusion of terbutaline have been reported to have fewer side effects than oral administration but have had no effect on rates of preterm birth or perinatal morbidity in randomized placebo-controlled trials.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. Final Result: Two of 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 is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested coverage for bilateral repair of eyebrow ptosis for treatment of her ptosis.  Findings:  The physician reviewer found that based on review of the available records, the patient has documented brow ptosis which is an abnormal condition of the body (Nahai). The brow is resting in an inferior position as demonstrated on the photographs provided for review and confirmed by the examination of the requesting provider. In addition, part of the obstruction from upper eyelid fullness may be directly related to the brow position. The abnormal structure is caused by a developmental abnormality contributed by the aging process. As the patient has aged, she has developed functional loss of vision due to inferior displacement of her brow as well as excess eyelid skin and ptosis of her eyelid that is contributing to her functional problem which would also be considered developmental abnormalities. Rohrich and colleagues describe these conditions in detail and that functional problems can result from these abnormalities. Consistent with the Reconstruction Statute, the requested surgery is being performed to improve function. The patient has stated that she has a functional problem related to her eyelids and brow and the providers documentation confirms their presence. The examination, as well as functional visual field analysis, confirms that the patient has a functional deficit and that brow elevation would be an effort to improve this functional deficit. Therefore, based on the entirety of the medical documentation and photographs, the patient has a functional deficit that surgical treatment could address. Finally, the surgery offers an attempt at functional improvement but would also offer more than a minimal improvement in the appearance of the patient. Thus, aesthetic improvement is only a secondary benefit and the primary purpose for the procedure is reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested weekly outpatient psychotherapy treatment for her bipolar disorder.  Findings:  The physician reviewer found that in this particular case, the patient had the abrupt onset of intrapsychic stress related to family issues. This was of particular significance as interpersonal functionality represented a domain of difficulty for her in the past. Considering this history and the well-delineated therapy focus, coupled with the potentially debilitating nature of comorbid bipolar disorder, weekly psychotherapy sessions were initially appropriate and reasonable. On the said date the therapist note identified the presenting problems of intermittent anxiety and agitation, malaise, interpersonal struggles and history of childhood trauma. The patients mood was described as above baseline while work and personal relationships are more stable with marked positive gains in both spheres. There was no documentation that indicated medication nonadherence, impairing mood symptomatologies, cognitive dysfunction, clinical deterioration or safety concerns. The patients Global Assessment of Functioning was 70, corresponding with some mild symptoms but good overall functionality with meaningful interpersonal relationships.  The therapist qualified the bipolar diagnosis as full inter-episode recovery suggestive that the primary treatment goal, stabilization of mood and anxiety, had been achieved.  Based on the documentation provided, the patient was stable and pursuit of the other therapeutic goal, further exploration of unconscious dynamics, did not necessarily require weekly sessions. Thus, as of the said date the services at issue were no longer medically necessary for treatment of the patients medical conditions. As such, a portion of the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Acthar Gel 400 units/5 mL vial. The records document that this patient presents with a diagnosis of IgA nephropathy. The patient has been treated with steroids, which the provider has recommended tapering, and switching to Acthar Gel. The U.S. Food and Drug Administration (FDA) has approved Acthar Gel for the treatment of patients with nephrotic syndrome (NS). Although Acthar Gel is not recommended for the treatment of patients with NS as first-line therapy, it is indicated as second-line therapy when initial treatment has failed or is not well tolerated. Madan and colleagues noted that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. The provider noted that this patients condition has not substantially improved with steroid treatment. Given this support, Acthar Gel 400 units/5 mL vial was and is medically necessary for treatment of this patient. Final Result: The reviewer determined 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 internal medicine with subspecialty certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus testing (CPT 84999, tumor necrosis factor antagonist test). Findings:  Three physician reviewers found the presence of antibodies alone does not necessarily result in reactions to infliximab or loss of response to infliximab, nor have threshold levels been established. Furthermore, studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The current medical literature reports contradictory outcomes and lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies (such as dose increase or change in medication) based on those thresholds, and then definitively establish that use of this testing improves outcome. For these reasons, the superior effectiveness of Prometheus testing (CPT 84999, tumor necrosis factor antagonist test) has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humatrope 6 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has a history of panhypopituitarism, growth hormone deficiency and adrenal insufficiency.Findings: The records support that this patient has growth hormone deficiency. While the benefits of growth hormone therapy replacement in adults with growth hormone deficiency is well documented, the medical literature and guideline recommendations do not differentiate between the different brands of medications for treatment of growth hormone deficiency. The American Association of Clinical Endocrinologists indicates in their guidelines the following:  In the United States, recombinant GH [growth hormone] is approved by the FDA [U.S. Food and Drug Administration] for adult GHD [growth hormone deficiency] and marketed by Pfizer (Genotropin), Eli Lilly (Humatrope), Genentech (Nutropin), Novo Nordisk(Norditropin), and Serono (Saizen). There is no evidence that one commercial product is more advantageous over the other, apart from differences in pen devices, dose increments and decrements, and whether or not the product requires refrigeration. In clinical efficacy, we do not advocate the use of one commercial preparation over another.  In addition, the Endocrine Society does not distinguish between brands when they refer to growth hormone therapy (Molitch, et al).  In the U.S. Food and Drug Administration approval letters for Humatrope and Nutropin, both medications have 191 amino acid residues and have a molecular weight of about 22,125 daltons. The descriptions for both brands of growth hormone medications are identical. As such, Humatrope is not medically necessary at this time because an alternative formulary medication, Nutropin, is available for this patient.  Therefore, Humatrope 6 mg has not been established as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined 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.