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 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 regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa once daily for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.  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: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested for a neuromuscular stimulator for treatment of her post-operative anterior cruciate ligament rehabilitation.  Findings:  The physician reviewer found that there is no adequate data strongly supporting the use of a neuromuscular stimulator (NMES) following knee surgery. Wright, et al. reviewed various studies regarding the use of NMES but concluded that patients utilizing the device may have achieved improved muscle strength, but the device does not appear to be a requirement for successful ACL reconstruction rehabilitation. Traditional physical therapy post-operatively is generally sufficient. Morissey, et al. noted that there was no significant difference in quadriceps muscle atrophy between patient groups using NMES and those not using NMES. The study by Holcomb concluded that NMES training may not be an effective alternative to voluntary muscle training in healthy patients.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for left knee arthroscopic surgery with meniscus repair and meniscectomy. The patient has been diagnosed with a left knee medial meniscus tear. Researchers reported a complete radial tear of the meniscus posterior root, which can effectively cause a state of total meniscectomy via loss of hoop tension, requires that the torn root be repaired. In this case, the patients left knee mechanical symptoms dictate arthroscopic repair or resection of the torn and unstable posterior horn of the medial meniscus. The patients provider is not requesting debridement of osteoarthritis but will address the medial meniscus, which appears to be the cause of mechanical symptoms. Conservative treatment has failed, and there is MRI evidence of a left knee medial meniscus tear. If repair is not feasible, partial resection of the medial meniscus will be necessary to manage the patients mechanical symptoms. The medical evidence supports the requested services in this clinical setting. Therefore, left knee arthroscopic surgery with meniscus repair and meniscectomy is medically necessary for the 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

The parents of a 12-year-old female enrollee requested authorization and coverage of two therapists for their daughter who is threatening suicide.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for the treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the allergen test (IgG test). Findings:  Three physician reviewers found that food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. The use of food-specific IgG level does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Final Result: Three reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in allergy and immunology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for bilateral occipital nerve blocks every six weeks. Barmherzig and Kingston evaluated the current medical evidence and recommendations for the diagnosis and management of occipital neuralgia. The authors concluded that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. However, the authors concluded that the available evidence is limited as most studies are noncontrolled. Urits and colleagues reported that, Conservative treatments such as medications and alternative therapies are first-line. The authors discussed treatment options for patients with refractory symptoms to include corticosteroid injections for short-term relief or as a transitional treatment bridge for patients who may benefit from neuromodulation therapies. In this case, the patient has chronic daily headaches that have been characterized as migraines. The records do not document occipital-based headaches or confirmation of tenderness to palpation over the occiput. The patient has been undergoing Botox injections for the migraines with 50% pain relief. The treating provider has recommended ongoing occipital nerve blocks to manage the patients chronic daily headaches. The most recent peer-reviewed literature regarding occipital neuralgia and treatment options does not confirm that occipital nerve blocks are superior to standard therapy. Moreover, there is a lack of data to support occipital nerve blocks as a method of durable pain relief for this condition. Therefore, bilateral occipital nerve blocks every six weeks were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the bilateral occipital nerve blocks every six weeks were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not and 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: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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

The mother of a 10-year-old male enrollee requested authorization and coverage of an insulin pump. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees diabetes mellitus.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Euflexxa injections for the right knee and/or left knee. The enrollee has osteoarthritis of both knees that causes pain. She received viscosupplementation injections one-year prior that provided eight months of pain relief. Her knee pain was preventing her from engaging in her regular physical activities. X-rays and a physical examination were consistent with tricompartmental knee osteoarthritis. A sports medicine note indicated the enrollee had tried physical therapy without relief from pain, but Euflexxa injections had helped for about a year. A professional society recommends the use of hyaluronic acid injections for appropriate individuals with knee osteoarthritis; based on the results of clinical trials.  The documents indicate the enrollee has a long-standing history of bilateral knee pain. The enrollee has completed physical therapy for several years without improvement, but has demonstrated considerable improvement, with lasting resolution of symptoms, with prior injections. The use of hyaluronic acid injections is standard practice; part of the nonsurgical treatment options to address mild to moderate osteoarthritis. A literature review revealed that intra-articular hyaluronic acid can offer low-risk, symptomatic benefits to those with knee osteoarthritis. These outcomes are demonstrated as improved overall knee health and delays in time to total knee replacement.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 evaluation of the enrollee, who presented for a breast screening mammogram. Findings:  2/3 of the physician reviewers found that the patient is a female with positive family history of breast and ovarian cancer. She had screening mammogram including digital breast tomosynthesis which showed no evidence of cancer. The Health Plan has denied reimbursement of the digital breast tomosynthesis portion of the examination as investigational. There is evidence based support for the service at issue. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective to the patient than had her examination been performed using two dimensional imaging alone. Final Result: 2/3 of the 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage of MRI of the lumbar region. The American College of Radiology (ACR) appropriateness criteria for the evaluation of low back pain notes that most patients presenting with uncomplicated acute low back pain or radiculopathy do not require imaging. However, the ACR recommends that if symptoms persist following four to six weeks of conservative management, if there is suspicion for serious underlying conditions, or if the patient is a surgical or intervention candidate, then MRI of the lumbar spine may be appropriate. In this case, the patient is status post surgery with acute recent onset of low back pain, and has tried and failed anti-inflammatory drugs and physical therapy. An MRI may evaluate postoperative complications, such as a postoperative seroma compressing the nerve roots, a bone fragment, or residual disc herniation. Given that this patient has worsening symptoms following surgery and has exhausted  conservative therapy, the requested MRI is medically indicated. Therefore, MRI of the lumbar region is medically necessary for the evaluation of this patient.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 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 Harvoni for treatment of her hepatitis C virus (HCV).   Findings:  The physician reviewer found that according to the recommended joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), the recommended regimen for genotype 6 treatment-naive patients with and without cirrhosis is daily fixed-dose combination of ledipasvir/sofobuvir for 12 weeks. However, in this case, there is a lack of documentation demonstrating that the patient has persistent or active HCV infection. The RNA (ribonucleic acid) quantitation provided showed a relative low viral load that had not been confirmed by retesting for a considerable period of time. Therefore, treatment with Harvoni has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in 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

The parent of a 15-year-old female enrollee requested  pharmacogenomic testing for medical evaluation of the enrollees behavioral health condition.  Findings:  Three physician reviewers found that pharmacogenomic testing is not likely to be more effective for this patient than other available options. The patients primary diagnosis is eating disorder with symptoms of restriction and purging. The treatment for this condition is psychotherapy including individual, group and family therapy.  The therapist appears to be appropriately working with this patient and has discussed a more intensive level of care.  The patient has also been seen by a psychiatrist who has utilized fluoxetine and venlafaxine.  Pharmacogenomic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date 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. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The patient presented with ear pain, nasal obstruction and sinus congestion. He denied chest pain, cough, fatigue, shortness of breath, nausea and fever. Given the non-emergent nature of the patients symptoms, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewers determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). TMS is indicated for the treatment of patients in the acute phase of major depression. Given that this patient is still experiencing symptoms of major depressive disorder, the requested treatment of TMS meets the criteria for medical necessity. The patients Personal Health Questionnaire 9 (PHQ-9) scores have historically indicated that he experienced some improvement in depressive symptomatology during the course of TMS. However, he still reports symptoms of major depression, which supports additional TMS sessions. The patient waited a 90-day period before requesting additional repetitive TMS sessions. Given the persistence of his symptoms, the requested TMS is considered part of a prolonged initial treatment phase. Moreover, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested TMS 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 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.