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

A 53-year-old male enrollee has requested implantation of toric intraocular lenses for the treatment of his astigmatism. Findings:  Three physician reviewers found that conventional intraocular lens implantation is generally accepted as a safe and effective treatment in this setting. Toric intraocular lenses are considered premium lenses and are not covered by the Centers for Medicare and Medicaid Services (CMS). The use of toric intraocular lenses is considered to be mainly for comfort and convenience to eliminate the need for eyeglasses or contacts. There is no evidence that toric lenses are associated with clinically significant improvement in vision as compared to conventional monofocal intraocular lenses combined with the use of eyeglasses or contacts. While implantation of toric intraocular lenses may be desired by patients to avoid the use of eyeglasses or contacts, the device is considered an elective adjunct to cataract surgery and is not indicated from a medical standpoint.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested  C4-5, C5-6 anterior cervical discectomy and fusion with allograft  for treatment of her cervical spondylosis with myelopathy. Findings:  Three physician reviewers found that the current medical evidence does not support the requested services in this clinical setting.  This patient was noted to have an assessment of cervical spondylosis with myelopathy.  However, there was a lack of physical examination findings noted for the patient to warrant the surgical request.  The only objective finding noted for the patient was bilateral hand numbness.  She was noted to have a diagnosis of multiple sclerosis.  The records indicated that the patient had not failed conservative treatment prior to the request for a surgical intervention to the cervical spine.  The medical evidence does not support the use of recombinant human bone morphogenetic protein for the treatment of this patient.  Therefore, the requested C4-5, C5-6 anterior cervical discectomy and fusion with allograft is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested injection therapy (sclerotherapy) for treatment of her venous disease.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature demonstrates that the procedure requested is likely to be more beneficial for treatment of the patients medical condition than standard therapies. The severity of the patients symptoms and the failure of conservative management including use of compression stockings have been sufficiently documented.  There is also documentation of absence of DVT and absence of GSV and SSV reflux on the right leg. Injection therapy (sclerotherapy) is indicated for treatment to the right GSV or SSV in this setting. Therefore, the planned sclerotherapy is appropriate treatment for the patients condition.
Appeal type: Urgent Care
Decision: Upheld

A 21-year-old female enrollee has requested emergency services for the treatment of her medical condition.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. 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.This patient presented with complaints of back pain for a six day duration. She had been evaluated in the ED for the same symptoms three days prior.  She was medicated and referred back to her primary care physician. She did not contact her primary care physician following the initial ED visit. The medical records do not document any acute neurologic deficit. The patient appeared in no distress. She had not sustained any acute injury. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergency basis. A prudent layperson in the patients circumstances would not have reasonably believed she was experiencing a medical condition that required immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient hospital admission for evaluation of the enrollees left-sided neck pain.Findings:  The physician reviewer found that although the documentation indicates the patient should have been placed on observation status to allow time for neurosurgical consultation and repeat examination, there is no documentation of intravenous heparin, surgical treatment, or interventional neurological treatment to support an indication for inpatient admission. Observation status would have been adequate to safely monitor the patient due to the unstable nature of the artery dissection. 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 with sub-specialty certification in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for chemical denervation of the internal anal sphincter with Botox injection. Current medical literature supports the use of Botox injections for the treatment of anal fissures. The American College of Gastroenterology clinical guideline for management of benign anorectal disorders reports that the injection of botulinum toxin into the internal anal sphincter allows healing in 60% to 80% of fissures, and at a higher rate than placebo. Bobkiewicz and colleagues report that botulinum toxin is an accepted method for the management of chronic anal fissure. Sahebally and colleagues found that botulinum toxin has fewer side effects than topical nitrates with similar efficacy. In this case, the patient had an anal fissure with rectal bleeding. In this clinical setting, a botulinum toxin injection of the anal sphincter was medically indicated. Therefore, chemical denervation of the internal anal sphincter with Botox injection was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 62-year-old who is overweight and has prediabetes. Laboratory results dated 4/15/22, noted a HbA1c of 5.9. On 6/7/22, the patient reported weight gain while being treated with Prednisone 5 mg for a prior kidney transplant. On 6/21/22, the patients body mass index (BMI) was noted to be 28.34 kg/m. Their physician has prescribed therapy with Ozempic. The Health Plan indicates that the requested medication is not medically necessary for the treatment of the patients medical condition. At issue in this case is whether an Ozempic 0.25/0.5 mg pen is medically necessary for the treatment of this patient. Gadde and colleagues note that obesity continues to be among the top health concerns across the globe. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies which are available for weight management. Knudson and Lau note, Ozempic (semaglutide) is a member of a class of medications known as GLP-1 analogs. These medications improve glycemic control, reduce body weight and decrease cardiovascular risk. Cornell stated that multiple studies have demonstrated GLP-1 receptor agonists ability to promote weight loss, via reduced appetite and energy intake, and delayed gastric emptying, and the likelihood of health risks associated with these medications are low. In this case, the patient is overweight with documented weight gain and prediabetes for which the effects of the Ozempic could be beneficial. Therefore, an Ozempic 0.25/0.5 mg pen is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested care by a tertiary level provider for treatment of the enrollees post concussive syndrome.  Findings:  The physician reviewer found that cases of concussion in sport where clinical recovery falls outside the expected window should be managed in a multidisciplinary manner by providers experienced in sports-related concussion. Important components of management after the initial period of physical and cognitive rest include therapies such as cognitive, vestibular, physical and psychological therapy, consideration of assessment of other causes of prolonged symptoms and possibly commencement of a graded exercise program at a level that does not exacerbate the patients symptoms. This patients records do not indicate that her providers are not appropriately trained to provide care for her post-concussion syndrome. Further, there is no evidence in the records to support that a change of provider will be detrimental to the patient. Therefore, the requested care by a tertiary level provider is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested for Humatrope 24mg for treatment of the enrollees short stature. Findings:  The physician reviewer found that there is no documentation that this patient met criteria for small for gestational age with failure to catch-up in growth by three years of age.  Based on review of the growth charts, the patients length and weight were within normal limits during infancy.  The patient does not have classic growth hormone deficiency, and there is no documentation that his adult height prediction prior to growth hormone treatment was short enough to meet criteria for idiopathic short stature.  Currently, at the age of 16, a slowing of growth velocity is expected once past the pubertal growth spurt.  In the absence of data on pubertal examination and bone age findings, the medical necessity of continuation of growth hormone therapy cannot be determined.  All told, Humatrope 24mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested a compression unit for the legs for treatment of her edema.  Findings:  The physician reviewer found that in this case, the records indicate that the patient has had stable 1+ pedal edema.  In March 2013, the patients provider recommended elastic hose, and a diuretic was prescribed.  However, there is no documentation that the patient has been treated with elastic hose or other compression garment.  This would be the appropriate first-line intervention for this patients condition, along with leg elevation and an active exercise program.  All told, the requested compression unit for the legs is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir (Viread and Vemlidy) compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate, which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including osteopenia and renal disease. For this reason, Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 32-year-old male enrollee has requested for emergency services indicating that the services at issue were emergent in nature. Findings:  The physician reviewer found that the patient presented to the Emergency Department with an exudative infection of his throat (tonsils) that was obvious on visual inspection and was associated with significant pain, enlarged regional lymph nodes and a high pulse rate. These symptoms had been progressing over a two-day period and had reached the point where a prudent layperson would reasonably expect that he had developed an emergency medical condition which required immediate attention.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as extremely dense.  In addition, there was clinical evidence of breast lumps.  Breast tomosynthesis has been shown to be valuable in this clinical setting.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor, and more confidently excluding malignancy.  When there are questionably palpable breast masses, it is imperative to exclude a focal etiology.  Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested for a replacement prosthesis with a microprocessor-controlled knee for treatment of his knee amputation. Findings:  Two physician reviewers found that there is insufficient peer-reviewed evidence to medically justify the use of a microprocessor-controlled knee over a standard prosthesis. A standard prosthesis will provided sufficient stability and function to allow the patient to perform his activities of daily living. The transition from a microprocessor-controlled knee to a standard above the knee prosthesis is not likely to result in a loss of functionality.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female has requested reimbursement for an occipital nerve block injection. The Health Plan has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. A review of the records indicates the patient has a history of meningioma surgery, rheumatoid arthritis, and reactive situational depression. Her primary care physician noted  that a magnetic resonance image had shown a pituitary microadenoma.  The patient reported a six-month history of migraines, with increased intensity for the past two weeks. The migraines were associated with nausea, dizziness, light and sound sensitivity, and neck pain. She had been taking Norco for pain relief. The records noted that an episode of loss of consciousness occurred in October 2018 after she had hit her head. She had been prescribed Keppra since a meningioma removal in 2016. One reviewer found that the requested occipital nerve block injection was likely to have been of greater benefit than other treatment options. Final Result: Two of the three reviewers determined that the requested injection 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Upheld

A 44-year-old female enrollee has requested the medications Lyrica and Qualaquin for the treatment of her condition. Findings:  The physician reviewer found that Quinine has been the subject of an FDA drug advisory specifically declaring the use of quinine as too risky for the treatment of leg cramps. At the time the advisory was released, there were 665 reports of serious adverse events tied to quinine, including 93 deaths. Pregabalin is currently being studied for pain control in multiple sclerosis.  Its use prior to completion of this trial would be experimental and unproven. Neither medication is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient has documented coronary disease and hyperlipidemia with both severe intolerance to statin therapy and ineffective LDL lowering with Zetia medication. In this circumstance treatment with a PCSK9 inhibitor such as Repatha is reasonable, appropriate and standard accepted therapy in the medical community. Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria since there is documented intolerance to statins and continued significant LDL elevation in spite of treatment with Zetia. There are several randomized prospective trials that document safety and outcome improvement with the use of PCSK9 inhibitors in this setting. Thus, Repatha Sureclick 140 mg/mL is medically reasonable and appropriate in this clinical setting.  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 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: Medical Necessity
Decision: Upheld

A 38-year-old male has requested coverage for past anesthesia services provided during an esophagogastroduodenoscopy and colonoscopy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The American Society of Anesthesiologists noted that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel and may include varying levels of sedation, analgesics, and anxiolysis.  The American College of Gastroenterology states that the use of monitored anesthesia care is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of or anticipated intolerance to standard sedatives.  Additionally, patients of extreme age (younger than 12 years of age or age 70 or older), patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.  In this patients case, the medical documentation indicates the patient had no specific medical condition that necessitated the use of monitored anesthesia care for the elective procedures.  There was no medical documentation regarding prior issues with sedation.  The patient was an acceptable candidate for the standard of moderate sedation to be administered by the endoscopist.  All told, anesthesia services provided were not medically indicated in this patients case.