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

The patient is an eight-year-old male with a history of chronic and recurrent otitis media. Although no documentation regarding otitis media has been submitted, it is documented that the patients hearing screen was normal. In addition, notes from speech therapy document the patients gross and fine motor skills are within normal limits. Standardized testing included the CELF-4, which was within the average range. The articulation evaluation demonstrated a mild lisp. Speech therapy has been recommended once a week for 12 weeks. The Health Plan has denied authorization for the requested therapy. Limited evidence has been submitted to support the requested therapy. There is little evidence that the patients mild articulation disorder is related to the otitis media he experienced as an infant. Furthermore, with a normal hearing screen it is less likely the patients articulation disorder is associated with otitis media. Moreover, there is no evidence the patient could not receive appropriate therapy from his school-based therapist. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
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 according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, 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. Harvoni has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. In this case, the patient presents with chronic HCV genotype 1b and is treatment-naive with non-invasive testing demonstrating advanced fibrosis. Therefore, Harvoni is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 56-year-old female enrollee has requested reimbursement for the occipital nerve blocks, and nerve testing for treatment of the enrollees fatigue, lightheadedness, and skin hypersensitivity.  Findings:  The physician reviewer found that per the medical records, the patient presented with hypersensitivity of skin, photophobia, hyperosmia, hyperacusis as well as lightheadedness when moving from a squatting position. The patient also had a complaint of migraine headaches. However, the medical records do not document use of traditional migraine headache therapies. Furthermore, there is a paucity of current studies which suggest that the use of occipital nerve blocks will improve abnormalities of the autonomic nervous system. There is a lack of documentation that the patient has greater occipital neuralgia. Furthermore, there is no literature which suggests that occipital nerve blocks can treat the patients symptoms. Given these findings, the occipital nerve blocks, and nerve testing were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the occipital nerve blocks, and nerve testing were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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 Epclusa for 12 weeks for treatment of the enrollees 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. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Upheld

An enrollee has requested reimbursement for a computed tomography (CT) of the heart without contrast. Based on the records provided, this patient presented with a strong family history of myocardial infarction and symptoms of pain, pressure, and heaviness in the legs. In this circumstance, guidelines for the management of cardiac risk established by the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) do not support routine advanced lipoprotein testing. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk. In addition, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the CT of the heart without contrast was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the CT of the heart without contrast was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for an annual breast screening examination. Findings:  The 3 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 particular patient, there are two separate indications for tomosynthesis. First, she has breasts that have been described as being dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Second, the mass that was discovered in the subareolar area of her right breast can be better evaluated with the addition of tomosynthesis.  Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 a LifeVest wearable cardioverter defibrillator for treatment of her ventricular tachyarrhythmias. Findings:  The physician reviewer found that the patient presented with an out-of-hospital cardiac arrest due to ventricular fibrillation. The cause of the arrest is not clear. In this circumstance of a primary cardiac arrest due to ventricular fibrillation of uncertain cause, treatment with an implantable defibrillator is indicated and considered the standard of care in the medical community. The documentation provided for review does not provide a rationale for the delay an implantable defibrillator placement such as patient awaiting heart transplantation or an infectious process or other temporary condition that would preclude safe implantation of an implantable defibrillator at the time of discharge. For the reasons provided, the LifeVest wearable cardioverter defibrillator provided was not medically necessary in this clinical setting.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine and cardiovascular disease 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 authorization and coverage for L4-L5 decompression with coflex stabilization device placement for treatment of the enrollee, who has a history of left lower extremity pain and weakness. Findings:  2/3 of the physician reviewers found that the physician reviewer found current evidence-based literature and long-term studies support the use of coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis and low-grade spondylolisthesis. This patient presents with persistent and worsening low back pain radiating into the left lower extremity with give-way weakness, numbness and tingling. She had significant functional limitations in activities of daily living. Clinical examination findings have documented motor and sensory deficits consistent with imaging evidence of severe central canal stenosis and left neural foraminal narrowing at L4-L5 with left L4 nerve root impingement. She has failed physical therapy, medications, and activity modification. The medical evidence supports the requested services in this clinical setting. All told, L4-L5 decompression with coflex stabilization device placement is likely to be of greater benefit than other treatment options. Final Result: 2/3 of 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

The parent of a 5-year-old female has requested coverage for 60 sessions of physical therapy, at a frequency of 3 to 5 sessions per week for treatment of her multiple medical conditions.  Findings:  The physician reviewer found that accepted guidelines (Centers for Medicare and Medicaid Services) for continuation of physical therapy indicate that there must be documentation of significant progress toward goals as well as an expectation of significant progress in a reasonable period of time. The documentation provided by the patients physical therapist is inadequate to demonstrate that the patient has made significant functional gains throughout her physical therapy. The progress report provided does not document that the patient has met her six month goals. Further, no standardized testing or comparison to baseline data is documented in the records provided. In the absence of such documentation, there is insufficient evidence demonstrating that the patient is likely to benefit from continued physical therapy. Thus, based on the clinical documentation submitted, the requested 60 sessions of physical therapy at a frequency of 3 to 5 sessions per week is not medically necessary. The patient should receive 6 additional physical therapy visits to thoroughly train the family on a home program and then receive quarterly monitoring to assess progress or regression.  (This decision partially overturned the denial)
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested inpatient residential treatment for medical treatment of his anxiety, depression, substance use, and agoraphobia.   Findings:  The physician reviewer found that the patient willingly attended and participated in groups, he had support systems in place with his family and friends, and he had a sponsor. There was no evidence of suicidality or homicidality, or threats of harm to others. His symptoms of anxiety and depression fluctuated and were reported as moderate in nature, which did not require treatment at the inpatient rehabilitation level of care. He was medically stable and was not at imminent risk of relapse due to comorbidity, nor were there acute changes in his condition that would indicate an imminent risk of relapse. All told, the patient did not require 24-hour inpatient supervision and did not meet the medical necessity criteria for inpatient rehabilitation.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of an 11-year-old male enrollee has requested for a quantitative electroencephalogram (QEEG) evaluation and neurofeedback treatment for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  Three physician reviewers found that there is inadequate scientific evidence demonstrating that the requested services are likely to be more beneficial than available standard therapy for the patients medical condition. The American Academy of Pediatrics Practice Guidelines for ADHD identifies several evidenced based interventions for ADHD including behavioral and pharmacological interventions and indentifies the need to evaluate and assess for co-morbidity. The National Resource Center for ADHD has reported that while neurofeedback continues to be an intervention that generates much interest and attention, the current research does not support conclusive claims about its efficacy. All told, there is a paucity of data concluding that quantitative EEG evaluation and neurofeedback is likely to be more beneficial for the treatment of ADHD than other standard evidenced based treatment modalities currently available.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested upper and lower blepharoplasty for the treatment of her chronic blepharochalasis. Findings: The physician reviewer found that blepharoplasty procedures and repair of blepharoptosis are considered functional/reconstructive surgeries when implemented to correct visual impairment due to dermatochalasis, blepharochalasis, or blepharoptosis, symptomatic redundant skin weighing down upper lashes, chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin and prosthesis difficulties in an anophthalmic socket, according to the American Academy of Ophthalmology (AAO). Documented patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis. Photographs should demonstrate that the upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex, the upper eyelid skin rests on the eyelashes, the upper eyelid indicates the presence of dermatitis or the upper eyelid position contributes to difficulty tolerating prosthesis in an anophthalmic socket. This patients photos do not show significant dermatochalasis, and the records do not describe a functional impairment due to upper and lower lid skin excess. In addition, visual field studies are not provided for review. The AAO guidelines are not met.
Appeal type: Urgent Care
Decision: Overturned

A 31-year-old female enrollee has requested urgent care services.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the said date. California law defines an emergency medical condition as 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 to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patients presenting signs and symptoms were painful urination, blood clots in urine, frequency, urgency, back pain, abdominal pain, and yellow appearing skin. The patients symptoms were consistent with several medical conditions that could have resulted in serious jeopardy to the patients health such as pyelonephritis, hydronephrosis, malignancy, liver dysfunction, and others.  Thus, the patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV). Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), 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 recommendation by the AASLD/IDSA is not to deny patients treatment if they have early stage disease, but to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. As such, the daily fixed-dose combination of ledipasvir /sofosbuvir for 12 weeks as recommended by AASLD/IDSA guidelines for treatment-naive patients with HCV genotype 1a infection is medically necessary. 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.