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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in both knees.Findings:  Two of the three physician reviewers found that this patient has a history of chronic bilateral knee pain and swelling. She has been diagnosed with bilateral knee osteoarthritis, although the severity of the osteoarthritis is not documented in the submitted medical records. Clinical examination findings have documented mild effusions. She reports increased difficulty in walking due to her bilateral knee pain. She is concerned regarding the chondrotoxicity of repeat corticosteroid injections. Given this patients clinical findings and failure of activity modification and medication trials, including corticosteroid injections, a trial of viscosupplementation is medically reasonable. In sum, Orthovisc injections in both knees are likely to be superior over other treatment options.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 orthopedic surgery 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: The patient has requested authorization and coverage for electric breast pump. The American College of Obstetricians and Gynecologists (ACOG) endorse and encourage breastfeeding. Per ACOG, in clinical circumstances where breastfeeding is challenging, pumping breast milk is an acceptable alternative. Breast pumping is most effectively performed with an electric breast pump. In this situation, the patient has overproduction of breast milk, which could lead to infection and difficulty for the infant latching. For these reasons, the requested electric breast pump is medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 obstetrics and gynecology 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 male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that review of the submitted documentation establishes the medical necessity of the requested medication. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, this patient fits in to the unique patient populations who develop recurrent HCV infection post-liver transplantation. In addition, given his status as a post-liver transplant patient, the patient qualifies for AASLD/IDSA's Highest Priority for immediate treatment of his HCV. Therefore, the requested medication is medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus.  Findings:  Two physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. For treatment-naive genotype 1 patients, therapy is recommended with Harvoni as a Class I, Level A recommendation. 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. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni should be considered medically necessary for eight weeks in this case. 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of his medical condition. Findings:  The physician reviewer found that the request for Norco is not medically necessary for treatment of the patients medical condition. According to researchers, several prominent guidelines recommend that patients on long-term opioid therapy have periodic urine drug monitoring for appropriate use. In this case, the patient presents with chronic pain of the lower left extremity. The patient has had inconsistent drug testing, for which his provider has been weaning down his medication. Based on the above, the request for Norco is not indicated for this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

 The enrollee is requesting authorization and coverage for the medication Epclusa, 400-100mg, for 12 weeks. The enrollee has hepatitis C virus (HCV), treatment naive, with elastography showing stage F2 (moderate) fibrosis. His HCV ribonucleic acid (RNA) was insufficient to obtain genotype. His gastroenterologist has requested authorization of Epclusa, 400-100mg, for 12 weeks. He states chronic HCV, even in those with limited liver damage, is linked to a higher likelihood of a wide array of health issues; such as cardiovascular disease, kidney disease and type-2 diabetes. Improving his quality of life is also critical; regardless of fibrosis score. Epclusa is the optimal treatment option for this enrollee. His provider notes the enrollee is no longer on a proton pump inhibitor (PPI) and therefore has no contraindications. The enrollee has Hepatitis C, fibrosis stage F2. The HCV RNA load was mildly elevated, but not high enough to obtain a genotype. Professional societies have issued guidelines for the treatment of Hepatitis C. It is the position of these societies that all those with chronic Hepatitis C should be treated unless they have a limited life expectancy. The physician reviewer found that  Epclusa has an overall cure rate of 98%. The enrollees viral load was still elevated and the enrollee already has a fibrosis score of F2. He should receive treatment that is active against all genotypes. Epclusa fulfills this requirement. It is therefore a medically necessary treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for continuous Synvisc injections every six months for treatment of the enrollees bilateral knee arthritis. Findings:  The physician reviewer found that 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. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested continuous Synvisc injections every six months are supported as medically necessary for treatment of this patients 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

A female enrollee requested Vikiera Pak for 12 weeks for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found thatper the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Therefore, Viekira Pak for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne genomic analysis. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of breast cancer.Findings There is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician or yields a result that is reliably clinically beneficial. There are various nonrandomized studies exploring the value of molecular profiling but these studies are not conclusive.  A randomized study by colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Some recent studies have expressed serious reservations about this approach in general. In sum, FoundationOne testing was not likely to have been of greater clinical benefit over the standard options available for the evaluation of this patients medical condition.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient hospitalization for treatment of her behavioral health conditions. Findings:  The physician reviewer found that submitted documentation supports a portion of the services at issue.  Documents from day to day seem to be very similar, with some changes to verbiage and some sentences remaining identical throughout the entire hospitalization period, making it difficult to assess what was actually done on a day to day basis to treat the patient.  The records do not provide detailed updates regarding her response to this therapy, and no adjustments to a failing plan were initiated by the treating psychiatrist.  The records do not indicate that specialized therapy was introduced or mentioned for chronic depression.  Therapy notes did not indicate significant progress in intensive dialectical behavioral therapy.  The records indicate that the patient could have been safely treated at a lower level of care once the patient was somewhat more stable after admission.  In sum, initial inpatient hospitalization was medically indicated for the treatment of this patient.  However, the medical records fail to demonstrate the medical necessity of inpatient hospitalization provided thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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 Sovaldi and Daklinza for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97%.  Per guidelines, the patient is ineligible for alternative regimens, which require interferon, due to the presence of possible immune-mediated disease. In addition, delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 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: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested for a Hoveround power wheelchair for treatment of her condition. Findings:  The physician reviewer found that it appears that the mobility device is requested mainly for community mobility.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions (Class I, Level A recommendation). Treatment of patients with HIV is assigned high priority by the AASLD/IDSA guidelines due to high risk of complications.  Treatment-naive patients are recommended to be treated with Harvoni for 12 weeks (Class I, Level A recommendation). In this case, Viekira Pak is contraindicated. AASLD/IDSA guidelines have a Red Box warning stating that Viekira should not be used with efavirenz, which is a component of Atripla. For the reasons provided, Harvoni is medically necessary for treatment of this patients HCV.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.Findings: The physician reviewer found that The patient presented with an unspecified traumatic injury to his face, resulting in displacement of tooth number 9, and possibly another tooth and/or teeth. According to the documentation submitted for review, the initial injury occurred and the patient was treated by an oral surgeon, who repositioned the displaced tooth and/or teeth. The patient was seen by an orthodontist. In a letter by the orthodontist states that as a result of the traumatic injury, the patients maxillary left incisor tooth number 9 was malpositioned and in traumatic occlusion with the opposing teeth. The patient was treated with a removable orthodontic appliance to move this tooth back into a normal relationship with the lower teeth, in order to prevent damage to the tooth and supporting structures. The patient has requested reimbursement for medical services provided. At issue in this case is whether the enrollee received emergency medical services on the dates 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. The medical services provided were not necessary for treatment of an emergency medical condition. In general, a traumatic injury to a tooth should be treated as soon as possible, as the prognosis is generally better if treated sooner, although this varies depending on the type of injury. In this case, the patient was injured and his tooth was manually repositioned by an oral surgeon. The orthodontic treatment provided was follow-up care, as evidenced by the fact that this treatment was provided 10 days after the injury. There was no emergent medical condition noted in the records submitted for review. In sum, the services at issue were not necessary for treatment of an emergency medical condition. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair for treatment of the enrollees obesity. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient is an adult with morbid obesity. The patient underwent the lap vertical sleeve gastrectomy in 2005 but remains morbidly obese with a BMI of 46 kg/m2. Re-operative bariatric surgery is a potential treatment for persistent weight loss and duodenal switch procedure affords durable weight loss of any bariatric procedure. The duodenal switch procedure involves a sleeve gastrectomy and a malabsorptive intestinal bypass. The duodenal switch is performed either is a staged or stand-alone primary procedure. Although the patient is a potential candidate for re-operative bariatric surgery, the medical necessity cannot be considered at this time given that there is no individual dietary evaluation provided for review to ensure that this patient is familiar with and understands the increased risk of micronutrient, fat soluble vitamin and protein deficiency associated with the duodenal switch procedure. Also to ensure that there are no baseline micronutrient deficiencies present currently and to review eating behaviors. There was mention of attendance to a nutrition class, but given the increased risk of protein and vitamin deficiencies associated with duodenal switch procedure, a group class would not be considered sufficient or appropriate to determine the patients understanding, and likelihood of compliance with necessary supplements. Due to lack of an individual dietary evaluation, the requested procedure is not indicated in this clinical setting. Moreover, there is a lack of clinical evidence that hiatal hernia repair which was reported as small on upper gastrointestinal study would warrant primary hiatal hernia repair if not for bariatric surgery. Given this, and that the duodenal switch procedure is not supported at this time due to lack of documentation of completion of a comprehensive multidisciplinary evaluation, the hiatal hernia repair alone would not be supported as medically necessary. Final Result: The reviewer determined that the requested procedure 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 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.