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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with multiple sclerosis (MS), fatty liver, type two diabetes, and obstructive sleep apnea. The patient also has a history of depression, fatigue, and dizziness. On 10/16/18, the patient reported cognitive difficulties, fatigue after exercise, and numbness in the extremities. The patient has been treated with Vyvanse, Glucophage, Invokana, Tysabri, Valium, fish oil, and vitamin D3 5000 units per day. Physical examination findings on 10/16/18 included a slight tremor in the left upper extremity and decreased vibratory threshold bilaterally. A laboratory report dated 10/17/18 showed a vitamin D level of 37.5. The patient has requested reimbursement for a vitamin D screening test on 10/16/18. The Health Plan denied the request and reported the service at issue was not medically necessary for the evaluation of this patient. At issue in this case is whether the requested vitamin D screening test on 10/16/18 was medically necessary for evaluation of the patients medical condition. Vitamin D has a role in calcium physiology and bone health, but also has numerous potential extra-bone actions such as cardiovascular system protection, anti-infectious properties, anti-inflammatory properties, and immunomodulatory effects involved in autoimmune diseases such as type one diabetes and MS. Immunological and genetic studies in MS patients have suggested that abnormalities involving vitamin D metabolism are related to the risk of the disease. Most patients with MS have vitamin D insufficiency, including in the earliest stages of the disease. In the case of insufficiency, vitamin D supplementation should be undertaken in order to raise the vitamin D serum level up to the physiological range and maintain it within this range. In this case, the patient was diagnosed with MS and has a history of vitamin D deficiency. The medical evidence indicates an association of vitamin deficiency and MS. Vitamin D supplementation to optimal values must be achieved in patients with MS to improve neuronal function due to immunomodulatory effects. The level of vitamin D is important to measure and should be kept above 30 ng/ml range. Therefore, the vitamin D screening test that was performed on 10/16/18 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Oncotype DX testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this patients case.  Adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer. It is much more controversial as to its benefit in node negative (stage II) colon cancer, as in this patients case.  Most oncologists make this decision based on specific pathologic and clinical features in an individual case. Among these features that identify a higher risk of recurrence are a poorly differentiated cancer, lymphovascular invasion, and presentation with obstruction.  Another approach to this dilemma is the use of gene panels, such as Oncotype, which is a 12-gene panel.  This assay helps to predict the risk of recurrence in both stage II and stage III colon cancer, and does so beyond the usual clinical and pathologic features.  The medical evidence supports the use of Oncotype assay in assessing risk of recurrence and the potential value of adjuvant chemotherapy.  Therefore, Oncotype DX testing is likely to be superior over other methods of evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for topical solution Jublia (efinaconazole) for treatment of the enrollees onychomycosis. Findings:  The physician reviewer found that The submitted documentation fails to support the medical necessity of the requested medication in this clinical setting. According to the record, this patient has not failed at least one course of an oral antifungal. There are no fungal cultures to support the indication for Jublia. There is also no documentation provided to support the clinical complaint of pain. Additionally, a review of the documentation provided indicates that the patient has no contraindications to oral antifungal therapy.  For these reasons noted above, topical solution Jublia (efinaconazole) is not medically necessary for the treatment of this patients medical condition. 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 podiatry 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 57-year-old female with a history of right total knee replacement in 2005, kyphoscoliosis of the thoracolumbar spine and severe left hip dysplasia.  She has extensive degenerative joint disease with pain in the lower back, hips and legs.  The Health Plan recently authorized left total hip replacement.  The patient has requested authorization for a POV to assist with her mobility.  The Health Plan denied her request citing a lack of medical necessity.The records provided are not supportive of the patients need for a POV. Although the patient indicates she cannot operate a standard wheelchair, there is no documentation of weakness or impairment in the upper extremities. The providers note mentioned a walker but there is no assessment of the sufficiency of the assistive device. The record does not include a specific evaluation of the patients mobility and there is no indication of a need for a POV within the home. The patent has been authorized for hip replacement surgery and the Health Plan appropriately stated that physical therapy would evaluate her need for a POV postoperatively.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity related comorbidities.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested for speech therapy for treatment of the enrollees severe receptive and expressive language delays and articulation delays. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial. All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The representative of a 46-year-old female enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing care. The documentation does not support the medical necessity of skilled nursing services for treatment of this patients medical condition from August of 2018 forward. The current medical literature states that there are rehabilitation interventions for patients with disorders of consciousness, which are established in clinical practice and supported by expert opinion, that do not need to be provided in the skilled nursing facility setting. The patient requires gastrostomy and tracheostomy care. However, the patient is medically stable and these services do not need to be performed by a trained medical provider in a skilled nursing facility. Moreover, the patient does not require therapy services with the specialized skill, knowledge and judgment of a qualified therapist. The patient has been receiving therapy, but progress has been limited due to cognition and limitations in function. The records indicate that overall, the patients exercises do not require the services of a skilled therapist. Given these findings, the skilled nursing care provided was not and is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 emergency medical services provided at the Alta Bates in Berkeley, during the course of the delivery of her baby. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided during the course of the delivery of her baby were not necessary for treatment of an emergency medical condition. Women with late-term pregnancies are at risk of oligohydramnios. If oligohydramnios is detected at term or beyond, delivery usually is indicated. In this case, although induction of labor was indicated due to the oligohydramnios, the timing of this induction was not emergent. There was no indication of fetal distress requiring emergency delivery since the patient labored for days prior to her vaginal delivery. Therefore, the medical services provided during the course of the delivery of her baby were not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LifeVest Wearable Cardioverter Defibrillator for treatment of his medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the device at issue in this clinical setting.  Initially, after implanted defibrillator leads became infected and required removal, the use of an external wearable defibrillator was reasonable and appropriate since there was still an indication for defibrillator placement.  However, once a follow-up echocardiogram reported significantly improved left ventricular ejection fraction, there was no longer an indication for a defibrillator (implantable or external) in the absence of documented syncope, sustained or inducible ventricular tachycardia or aborted sudden cardiac arrest.  Therefore, the LifeVest Wearable Cardioverter Defibrillator was not likely to have been of greater benefit than other treatment options.Final Result: The reviewers determined that the device at issue was not likely to be more beneficial for treatment 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.  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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested OxyContin time release and Fentanyl transdermal patch for treatment of her chronic leg pain and low back pain.  Findings:  The physician reviewer found that the record reflects that the patient is diagnosed with multiple sclerosis (MS) and as such, the pain complaints related to this diagnosis falls under palliative medicine. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. According to the submitted records, the first step in the WHO ladder has not been documented. The records do not reflect that non-opioid treatment options have been utilized and failed. Also, the treatment plan for this patient does not show that she has tried other non-pure mu-agonist drugs that have long lasting duration. Furthermore, the available research indicates the importance of utilizing interventional treatment plans for patients with chronic pain who may be at risk for opioid misuse. Treatment plans should closely monitor new increases in medications. The available literature also recommends specific behavioral treatment plans designed to improve adherence with prescription opioids among persons treated for chronic pain. Finally, ample research shows how symptoms of MS should be treated. According to the records, the patient is on medication for her MS with fair to stable results. The patient noted that she has not experienced any new changes regarding her MS symptoms. But aside from medication, the documents provided do not discuss if standard MS treatments, both pharmacological and physical, have been performed and failed for this patient. Consideration of other management options for the patients MS may help improve her chronic pain symptoms. For the above stated reasons, the requested OxyContin time release and Fentanyl transdermal patch are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewers 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: Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain management 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 authorization and coverage for lipectomy, head and neck and rhytidectomy for treatment of the enrollee, who is status post weight loss surgery, and are not reconstructive in nature.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested lipectomy, head and neck. The records do not support that a functional impairment is present related to her redundant skin. In addition, the photographs show mild to moderate findings. In this patients case, the requested lipectomy, head and neck is not reconstructive in nature. This patients condition does not constitute an abnormal structure of the body. The fat distribution of the neck, which would be treated in a lipectomy, appears normal in the photographs. The records do not indicate that the requested services will improve function, as there is a lack of documentation of a functional deficit. Additionally, the requested lipectomy, head and neck is not likely to provide more than a minimal improvement in the appearance of the patient. The requested rhytidectomy is not medically necessary for the treatment of this patient. There has not been adequate documentation of any functional impairment, and the photographs do not support an abnormal appearance. This patients condition does not constitute an abnormal structure of the body. The photographs show that she has some mild to moderate redundancy, but this is not considered an abnormal structure. The requested services will not improve function, as there is a lack of evidence of a functional deficit. Additionally, the requested rhytidectomy is not likely to provide more than a minimal improvement in the appearance of the patient. In sum, the requested lipectomy, head and neck and rhytidectomy are not medically necessary and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xyosted auto-injection 75 mg/0.5 mL.Endocrine Society and European Association of Urology guidelines state that two morning testosterone level below reference range are recommended prior to initiation of therapy for hypogonadism. Guidelines recommend measurement of luteinizing hormone (LH) levels and follicle stimulating hormone (FSH) to evaluate the type of hypogonadism. Additionally, guidelines also state patients should have classical androgen deficiency symptoms. Moreover, the guidelines recommend monitoring testosterone, hematocrit, prostate-specific antigen, and lipid profile continuously after initiating testosterone replacement therapy. In this case, the patient did not have two morning testosterone levels tested. Additionally, LH and FSH levels were not documented. Clinical documentation supporting continuous monitoring of testosterone replacement therapy is not available. There is inadequate documentation to support the diagnosis and type of hypogonadism. Therefore, Xyosted auto-injection 75 mg/0.5 mL is not medically necessary for the treatment of the patients medical condition. 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 urology 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.