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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Dexcom G5 continuous glucose monitor. Continuous glucose monitoring systems (CGMS), including real-time systems, have U.S. Food and Drug Administration (FDA) approval. They are not the subject of Phase I-III clinical trials. The peer reviewed literature supports the long-term use of CGMS in adult patients. The ADA position statement on standards of medical care in diabetes states, Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults with type 1 diabetes. In addition the peer reviewed literature supports the use of long-term CGMS in patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia. There is evidence that real-time CGMS with an alarm function detects hypoglycemia, leads to an improvement in glycemic excursion, leads to a reduction in duration of hypoglycemia, and prevents hypoglycemic reactions in adult patients with type 1 diabetes. The ADA considers this to have a level of evidence of A which is Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered. This is based on a large scale trials published in the New England Journal of Medicine that showed that CGMS is effective in reducing HbA1c in adults with type 1 diabetes over a 6 month period. Furthermore, data from a meta-analysis of multiple clinical trials have shown benefits of CGMS in avoiding hypoglycemia in patients with Type 1 Diabetes. In this case, a CGMS device has potential benefits for the patient, as the patient has Type 1 diabetes, is on an intensive insulin regimen with sub-optimal glycemic control, has a history of hypoglycemic unawareness, and has nocturnal hyperglycemia. Under these circumstances, a Dexcom G5 continuous glucose monitor is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the 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 internal medicine, with subspecialty 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

A 64-year-old male enrollee has requested pelvic floor training with biofeedback for the treatment of his outlet dysfunction constipation. Findings:  The physician reviewer found that there is no effective therapy and treatment for constipation, other then biofeedback therapy. A review of the literature presented by the patient supports this position and provides adequate evidence that biofeedback results in positive outcomes in this patient population. Given the lack of treatment options available for the patients condition, the use of biofeedback therapy was medically reasonable and appropriate. The therapy received by the patient in this case was medically necessary to treat his pelvic floor dysfunction and should be covered by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested bilateral hip resurfacing for treatment of her hip pain.   Findings:  The physician reviewer found that documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. Based on the documentation submitted for review, the patient has a significant medical history and conditions for which bilateral hip resurfacing is contraindicated. The peer reviewed literature indicates that resurfacing in patients who are obese or overweight can result in significant complications.  Furthermore, bone density is a significant factor in determining patient selection for resurfacing. It was noted that the patient has a medical history of osteopenia, and the patient was noted to be a female.  In sum, the patient is noted to have significant comorbidities which contraindicate the proposed procedure. The patients risk of complication is increased due to said comorbidities. Given the documentation submitted for review and the peer-reviewed literature, the medical necessity for bilateral hip resurfacing has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral sacroiliac (SI) joint fusion surgery for treatment of her medical condition. Findings:  Three physician reviewers found that bilateral sacroiliac joint fusion surgery is not likely to be more beneficial for treatment of her medical condition than any available standard therapy. In this case, the patient has not had a complete SI exam. Local SI tenderness is not diagnostic of SI joint disease, nor is a single finding as a positive thrust test confirmatory of SI joint disease. There is a lack of confirmatory evidence that she has SI joint pain or that the SI joint is her pain generator. Moreover, there is a lack of large, prospective, randomized, scientific, studies that have shown the long term safety and effectiveness of SI fusion for chronic degenerative disease of the SI joint. Thus, the proposed surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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 orthopedic surgery 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

The parent of a nine-year-old male enrollee has requested Vyvanse for the treatment of the enrollees attention deficit hyperactivity disorder. Findings:  The physician reviewer found that this patient has a diagnosis of ADHD for which Vyvanse is an FDA approved medication. Vyvanse is a prodrug of dextroamphetamine and offers certain advantages such as longer duration. Both efficacy and safety have been observed in the medical literature as noted in the article by Findling and colleagues. These determinations are also discussed by Najib in his publication regarding the use of Vyvanse in the treatment of ADHD. This patient has already responded well to Vyvanse as reported by both the provider and the patients parent. Vyvanse is medically appropriate in this setting and should be approved for treatment of his ADHD.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested a cervical artificial disc replacement surgery for treatment of her cervical radiculopathy and cervical spondylosis.  Findings:  Two physician reviewers found that there is insufficient medical literature supporting the use of cervical artificial disc replacement in this clinical setting. Although recently published reports cited above, analyzing the Mobi-C disc results are encouraging, longer term follow up studies are necessary before the safety and efficacy of the disc can be determined. In the study by Kim and colleagues, performed on 23 patients with degenerative cervical disc disease who underwent cervical disc replacement with Mobi-C disc prosthesis, the authors concluded that Mobi-C disc prosthesis provided a favorable clinical and radiological outcome in this study. However, long-term follow-up studies are required to prove its efficacy and ability to prevent adjacent segment disease (Kim et al). All told, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 12-year-old male enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) for treatment of the enrollees possible pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS).  Findings:  Two physician reviewers found that the patient was a normally functioning patient until about the age of 9. At this age, the patient began to develop severe behavioral changes consisting of severe anxiety, phobias and tics. Subsequently, he developed symptoms of severe abdominal discomfort, frequent vomiting, weight loss, and persistent psychiatric dysfunction requiring hospitalization. Laboratory studies recorded severe eosinophilia, intestinal parasites, but lacked a specific diagnosis. He was evaluated by multiple pediatric subspecialists including pediatric neurologists, psychiatrists, psychologist, and gastroenterologists again without any specific diagnosis, but a strong suggestion of Tourettes syndrome with tics and progressive obsessive-compulsive behavior. A pediatric rheumatologist noted that there was a possibility of a diagnosis of pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS). The patient had an elevated CD3 serum level which did suggest an immunological autoimmune abnormality. The provider recommended a trial of intravenous immunoglobulin (IVIG) for treatment of this possible disorder. The Health Plan denied the request for IVIG as its utilization in PANDAS is considered investigational. This patients diagnoses as supported in the chart include Tourettes syndrome with tics and obsessive-compulsive behavior. The provider considered the possibility of PANDAS based on the patients history and minimal laboratory confirmation of this diagnosis. PANDAS is essentially a clinical diagnosis with this patient demonstrating some of its characteristics, while he simultaneously evolved severe personality and behavioral changes. Initial reports of treatment of PANDAS, by either IVIG or plasmapheresis, noted patient improvement. Perlmutter and colleagues conducted a controlled study in which nine children who received IVIG with improvement at one-month and one-year follow-up when compared with controls. However, 10 years later Martino and colleagues commented that there was a lack of conclusive evidence that either antibiotics or immune modulation with IVIG were useful in the treatment of PANDAS. Currently, there is inadequate evidence or clinical support for the existence of PANDAS as a clinical entity. As such, IVIG in this patient is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an eight-week course of Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients.  Non-cirrhotic patients with viral load below 6,000,000 IU/mL can be treated with Harvoni for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  All told, the requested eight-week course of Harvoni is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested reimbursement for services. The services provided to this patient are supported as emergent. In this case, the patient has a history of small bowel obstruction. The patient presented with abdominal pain similar in character to prior small bowel obstruction. Imaging on presentation to the emergency department revealed a partial small bowel obstruction, and laboratory testing showed leukocytosis. The patients symptoms responded to intravenous opioid analgesia and antibiotics. In this clinical setting, it was appropriate for the patient to seek immediate medical attention as these complications could have been present given the patients history and presenting symptoms (Paulson, et al.; Loftus, et al.; Azagury, et al.). A delay in diagnosis and treatment of this condition could have placed the patients health in serious jeopardy, impaired bodily functions, and resulted in serious organ dysfunction. Colonoscopy can be appropriate to rule out organic disease as a cause for abdominal pain but was not supported given resolution of the patients abdominal pain and lack of hematochezia, diarrhea, or other findings which would warrant colonoscopy (Early, et al.). Given these findings, the services, with the exception of the colonoscopy, were emergency services provided for the treatment of an emergent medical condition as defined by California law. Final Result: The reviewer determined that a portion of the services at issue were emergency services as defined by California law for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for orthodontic braces. The submitted documentation fails to demonstrate the medical necessity of the requested services. In order to assess the need for orthodontic treatment, there are many objective tools. One commonly used tool is the handicapping labio-lingual deviation index, as used in this patients case. Convention states a score of over 26 on the handicapping labio-lingual deviation index is a severe malocclusion requiring intervention and thus defining medical necessity for orthodontic treatment. In this patients case, the handicapping labio-lingual deviation index was computed by the treating orthodontist to be 24 and computed on review to be 21, below the threshold for medical necessity. The treating orthodontist describes pressure placed on the posterior teeth due to the described crossbite. However, the radiographs provided show a level occlusal plane in the posterior segment which would minimize any of the described traumatic pressure in protrusion. There is a lack of support for the requested services in this clinical setting. All told, orthodontic braces are not medically necessary for the treatment of this patient.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 dentistry 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 Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C virus (HCV) are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. AASLD/IDSA guidelines further state that Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, as per the FDA recommendation, the patient should be approved for Harvoni for 12 weeks to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver  disease. Final Result:  Two 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of the abdomen. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Liposuction of the lateral abdomen is medically indicated in this clinical setting.  This patient has a significantly abnormal appearance due to previous treatments. Liposuction is an appropriate intervention in order to correct this abnormality.  In this patients case, the requested services are reconstructive in nature. This patients condition constitutes an abnormal structure of the body. The records document lateral abdominal excess following breast reconstruction using an abdominal flap. Although the requested surgery is not likely to improve function, it is likely to create a normal appearance to the extent possible. The requested liposuction of the abdomen is likely to provide more than a minimal improvement in the appearance of the patient. Therefore, the requested services are reconstructive in nature. All told, the requested liposuction of the abdomen is medically necessary and is reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 4.  Findings:  Three physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 4 infection in treatment naive patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. All told, the medical literature supports the requested Harvoni for 12 weeks as medically necessary for treatment of this patients hepatitis C viral infection. 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: The three 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis for evaluation of the enrollee, who was asymptomaticFindings:  All three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records noted dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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.