Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing to evaluate the her heart disease. Findings:  Three physician reviewers found that she was noted to have a history of vitamin D deficiency and diverticulosis, and she was status post colon resection. She also reported having difficulty absorbing folic acid. Advanced lipoprotein testing, methylene tetrahydrofolate reductase deficiency, factor V Leiden mutation and lipoprotein-A testing were ordered by the provider.  However, he did not provide any justification for this testing nor did he indicate how the data would be used for this patient. The current status of the peer reviewed literature is such that the additional benefits to health outcomes from advanced lipoprotein testing when compared to the use of standard testing has not been definitively proven. In addition, in this patients case the treating provider did not provide an explanation of how the data derived would be used in management of the patient. The medical evidence does not support the use of advanced lipoprotein testing when used to assess or manage the risk for heart disease. Final Result: The reviewer 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of his hepatitis C.  Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  According to the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver related comorbid conditions.  It is advantageous to treat patients before they progress to F3 or F4 fibrosis.  Based on published evidence of safety and efficacy, Sovaldi is medically indicated for the treatment of this patient.  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: All 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: Upheld

A 59-year-old female requested authorization and coverage of treatment with thalidomide. The Health Plan denied the request indicating that treatment with thalidomide is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested the real-time heart monitor for evaluation of his atrial fibrillation.  Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been of greater benefit than other methods of evaluation.  There is a lack of studies demonstrating the superior efficacy of the services at issue as compared to standard loop or event monitoring.  Real-time remote cardiac monitoring has not been subjected to rigorous medical outcomes analysis.  Real-time remote cardiac monitoring may be considered an appropriate alternative diagnostic modality for patients with recurrent, intermittent symptoms and non-diagnostic yield using standard event monitoring.  Based upon the current medical evidence, use of the real-time heart monitor was not likely to have been more effective than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections to both knees. A health technology assessment from the ECRI Institute concluded that evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. However, there are questions remaining about the most effective formulations, which populations benefit most, and whether hyaluronic acid injections combined with other agents will increase effectiveness. The American Medical Society for Sports Medicine (AMSSM) supports hyaluronic acid injections in the knees for patients who have failed to respond to conservative treatment and to potentially delay total knee replacement in patients with severe osteoarthritis and pain that interferes with functional activity. This patient presents with chronic bilateral knee pain with intermittent giving way of the left knee. She is status post bilateral knee anteromedialization osteotomy and medial patellofemoral ligament reconstruction in 2017, with subsequent deep implant removal from both knees. She reports limited ability to participate in physical therapy due to pain. Clinical examination findings are consistent with reported imaging evidence of degenerative changes. Conservative treatment has included physical therapy, activity modification, home exercise, NSAIDs, and corticosteroid injections with limited relief. Prior treatment with hyaluronic acid injections over the past 10 years provided significant benefit for six to eight months. The records document pain and functional limitations in addition to failure of comprehensive conservative treatment. In an attempt to potentially delay total knee arthroplasty, the requested Orthovisc injections to both knees are 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: Upheld

A 25-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for treatment of her medical condition status post heart transplant.  Findings:  The physician reviewer found that IVIG is used for the treatment of humoral or antibody mediated rejection and can also be used in prophylaxis. In this patients case, the records indicate IVIG was used in a prophylactic capacity immediately post transplant. This is consistent with standard of care, particularly for a patient who has had previous transplants and issues with antibody mediated rejection. From the documentation provided, it appears she completed a five treatment course of IVIG. However, the patients biopsy and laboratory work do not suggest current humoral rejection. Therefore, the previous use of IVIG was medically necessary but continued therapy would require further support. All told, the future use of IVIG in this patient is not currently supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A twenty-nine year-old female who underwent right above the knee amputation is requesting authorization of a microprocessor controlled C-Leg.Reviewers Findings:  The reviewing physician found that the submitted clinical information demonstrates a prosthetic with a microprocessor knee is medically necessary for this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoluminal ablation. The records provided for review indicate that this patient presents with venous insufficiency. Following physical evaluation and imaging, the patients provider charted that the patients symptoms are due to residual reflux in the saphenous veins. There is also adequate documentation that the patients symptoms are interfering with her ability to perform activities of daily living. In addition, there are imaging reports demonstrating arterial perfusion to the lower extremities bilaterally. There is no evidence of deep vein thrombosis (DVT). The provider has recommended endoluminal ablation of the patients venous reflux. Obi and colleagues assessed 2,661 veins in 1,803 limbs, in 1,406 patients who were treated for varicose vein disease. The authors noted that, Endovenous treatment of axial reflux was the preferred treatment in 89.1%, divided largely between radiofrequency ablation (55.2%) and endovenous laser ablation (33.9%). The authors concluded that patients reported improvements in swelling, itching, appearance, and work impact, as well as reduced sensations of heaviness, aching, and throbbing. Given this support, the requested endoluminal ablation of the right great saphenous vein 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 general surgery with subspecialty certification in vascular 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: Urgent Care
Decision: Overturned

A 30-year-old male enrollee has requested emergency services for treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the enrollees presenting history, believe he or she was experiencing an emergency medical condition requiring emergency medical services. Under Health and Safety Code 1317.1, an emergency medical condition means 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 in bodily function; or 3) serious dysfunction of any bodily organ or part. Given this patients history, he reasonably believed he needed to return for a wound check within 24-48 hours as he had been instructed on his discharge summary from the hospital. Specifically, after his wound had been treated, the emergency provider had instructed him to return for a wound check in two days. There is nothing in the discharge summary informing the patient to return only if there were signs of infection such as redness, swelling and pain. Thus, the patient followed the providers directions and presented to the ER for a wound check as advised. For these reasons, the patients decision to seek treatment in the ER for the wound check as recommended by the emergency provider was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested a PET scan for evaluation of his pancreatic cancer. Findings:  The physician reviewer found that prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include pancreatic cancer on its list of indications for PET scan. However, the National Oncologic PET Registry (NOPR, www.cancerpetregistry.org) was developed in response to the CMS proposal to expand coverage for PET scans to include cancers and indications not previously eligible for Medicare reimbursement. Pancreatic cancer is listed as appropriate for diagnosis, staging, restaging, and monitoring.  PET has shown itself to be sufficiently sensitive to be part of the evaluation of patients with pancreatic cancer.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic nephrectomy. Findings:  The physician reviewer found that the patient has presents with symptomatic left flank pain related to her massively enlarged left polycystic kidney. The left kidney is severely hydronephrotic and massively enlarged with no distal obstruction noted on imaging. Normal renal parenchyma is also not seen on ultrasound and CT imaging. It is the standard of care to perform a laparoscopic nephrectomy for symptomatic pain polycystic kidney, especially if there may be potential added pathology such as severely hydronephrotic or obstruction from a mass. However, it is important to determine why the left kidney is severely hydronephrotic or obstructed or if there is a solid mass to rule out cancer causing this obstruction. The referral to an in-network urologist at USC Keck is medically reasonable as the provider may pursue further work-up such as a CT urogram, magnetic resonance imaging (MRI) or a split renal scan, discuss the possible benefits of laparoscopic nephrectomy in the setting of a massively large left kidney, and the reduction in estimated glomerular filtration rate (eGFR) when left nephrectomy is performed. Of note, the patient does not have kidney failure, her creatinine is noted to be 1.0 with eGFR of 63, and performing a left nephrectomy will significantly reduce her eGFR, depending on how much function the left kidney is contributing. Therefore, the request for laparoscopic nephrectomy is not medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewers determined that the requested surgery is not medically necessary at this time for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld at this time. Credentials/Qualifications: Physician reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator. Researchers reviewed outcome measures and adherence data for patients treated with hypoglossal nerve stimulation for moderate to severe obstructive sleep apnea. The authors noted that hypoglossal nerve stimulation therapy is associated with good objective adherence, low morbidity, and improved OSA outcome measures. In comparing uvulopalatopharyngoplasty and hypoglossal nerve stimulation therapy, a study concluded, while both traditional surgery and hypoglossal nerve stimulation therapy were effective treatments for patients with moderate to severe OSA with CPAP intolerance, our study demonstrated that hypoglossal nerve stimulation is curative in normalizing the AHI to less than 5 in the majority of patients. In this case, the patient meets U.S. Food and Drug Administration (FDA) criteria for hypoglossal nerve stimulator. The patient has tried and failed CPAP treatment, and his AHI is within the appropriate range. Thus, the requested hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested 12 weeks of Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that according to the most recent 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. These 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested 12 weeks of Harvoni is medically necessary for treatment of this patients hepatitis C virus infection.   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: 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: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested for Genotropin for treatment of the enrollees short stature.  Findings:  The physician reviewer found that there is no evidence that all other causes of short stature and delayed skeletal maturation have been ruled out. Moreover, results of screening IGF-1 and IGFBP-3 levels have not been provided. Thus, there is insufficient evidence to be able to conclude that the patients short stature is idiopathic.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. This patient was still experiencing protracted withdrawal symptoms in the most recent records. The patient has reported hearing voices, anxiety, and agitation. The provider noted that the patients withdrawal symptoms have included paroxysmal sweating with visible moisture on his face, agitation, bone and joint aches, and palpable tremor. The patient has a diagnosis of uncontrolled diabetes mellitus with severe, potentially life threatening blood sugars. The ASAM confirms that diabetes is more difficult to manage in persons with substance use disorders. He is also hepatitis C and elevated liver enzymes. The patients overall mental status is sufficient to permit participation in this RTC. He is oriented to person, and place, but at times not the situation due to his persecutory beliefs and auditory hallucinations. The patient has been unable to control his substance use without 24-hour support. The patients perspectives impair his ability to make care decisions. Prior treatment with multiple RTC admissions and detoxification services resulted in relapse shortly after discharge. The patient remains at high risk for overdose or self-harm due to his severe addiction and comorbid impulsivity, psychosis, and persecutory beliefs. He has poor insight and judgment, which he has demonstrated by falling asleep while driving. He requires 24-hour support to work through his need for immediate gratification, impulsivity and self-sabotaging behaviors. He struggles with frequent nightmares and terrifying hallucinations that further perpetuate his suicidal risk. The patient continues to experience cravings and he is at imminent danger of relapse if not in a 24-hour treatment setting. The patients recovery environment is too chaotic to support his treatment goals and he is unsure where he will live after discharge. Given these findings, the RTC level of care services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in addiction 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.