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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  While Otezla is a U.S. Food and Drug Administration approved medication for the treatment of plaque psoriasis, the documentation provided does not indicate that this patient has tried and failed first line therapy with oral systemic agents such as methotrexate, cyclosporine or acitretin, in addition to Enbrel and Humira. He has tried and failed treatment with topical steroids and topical vitamin D analogues. However, there is no medical documentation to support an intolerance or contraindication to the use of methotrexate or acitretin. Therefore, the request for coverage for Otezla should be denied as there are alternative, preferred formulary treatment options available. As there are several other therapies, which are considered first line treatment options, Otezla is not medically necessary for the treatment of this 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 dermatology 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 reduction mammoplasty for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  The patient has well-documented, chronic back and neck pain with failure of reasonable conservative management, including chiropractic treatment.  Her activities of daily living are significantly affected with respect to her occupation.  Her examination and planned degree of resection are supportive of her significant macromastia.  Her condition of macromastia is causing functional problems, and she would likely benefit significantly from reduction surgery.  Breast reduction is a well-known procedure that directly addresses functional compromise.  The current medical evidence supports the requested services in this patients case.  All told, the requested reduction mammaplasty is medically indicated 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 physician reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested inpatient psychiatric services for treatment of his bipolar disorder and chemical dependency. Findings:  The physician reviewer found that this patient did not meet criteria for continued inpatient psychiatric hospitalization after the date in question. His treatment could have been managed at a lower level of care. A residential treatment program or a sober living arrangement combined with an outpatient chemical dependency program supervised by a psychiatrist would have been appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for warfarin/Coumadin and standing orders for Protime and international normalized ratio (INR) laboratory testing to be performed every three months. The medical evidence supports the requested medication and requested services in this clinical setting. This patient has recurrent PE/DVT and likely requires lifelong anticoagulation regardless of his factor V Leiden. Based on this patients medical history, warfarin/Coumadin is medically necessary. Coumadin is a drug that requires close monitoring. A level too low can result in increased risk of further blood clots, and a level too high can increase the risk of bleeding. Thus, ongoing INR testing is medically necessary. In sum, warfarin/Coumadin and standing orders for Protime and INR laboratory testing to be performed every three months are medically necessary for the evaluation and treatment of this patient. Final Result: The reviewer determined that the requested medication and requested services are medically necessary for evaluation and 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 hematology 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 Harvoni 90-400 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus. Findings:  The physician reviewer 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 limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, Harvoni is a recommended regimen for certain hepatitis C genotypes, but not others.  The AASLD and IDSA guidelines cite data showing increased survival with earlier treatment. 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: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested for continued residential eating disorder treatment for treatment of her condition. Findings:  The physician reviewer found that this patient required a RTC level of care, and will continue to require a RTC level of care for at least an additional 30 days (subject to reassessment at that time).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  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 case, the patients breast tissue was described as heterogeneously 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.  Thus, digital breast tomosynthesis was likely to be more effective than other methods of evaluating this patient.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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar spine magnetic resonance imaging (MRI). The Health Plan has denied this request indicating that the requested services were not medically necessary for evaluation of the patients spinal stenosis of lumbar region and neurogenic claudication. The submitted documentation supports the medical necessity of the requested services. Given the patients reported history of low back pain, difficulty walking, and the presence of neurologic symptoms and signs, the requested services are medically indicated. Plain x-rays are often of limited value in making the decision concerning surgery. In this patients case, the presence of diminished reflexes and urinary incontinence are signs that should not be ignored. Given the plan for surgery, an MRI is the best means to provide anatomic information. According to the medical records submitted, the patient has had conservative therapy. Therefore, lumbar spine magnetic resonance imaging (MRI) is medically necessary for evaluation of the patients medical condition. 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 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

The parent of a 13-year-old female enrollee has requested growth hormone therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation supports the requested therapy in this patients case.  Although the patients growth factors are normal and there is no known morphologic abnormality of the pituitary gland, this patient meets generally accepted criteria for a trial of growth hormone therapy for the diagnosis of idiopathic short stature.  Her height is more than three standard deviations below normal for age and gender.  Based on her bone age assessment and height measurement, the estimated final adult height prediction is approximately 49.  This patients growth velocity is poor despite signs of puberty, and all other known causes of short stature have been ruled out.  In this patients case, a trial of growth hormone therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature supports the provision of speech therapy services in conjunction with other forms of therapy for patients with autism spectrum disorders, especially at a young age, as is the case with this patient. Finally, California Assembly Bill (AB) 88 specifically lists autism spectrum disorders as a diagnosis that must be treated in parity with other medical conditions. The submitted documentation confirms the patients diagnosis of autism. As the above-cited literature demonstrates, speech therapy is well-accepted as standard treatment for patients with autism. Therefore, I have concluded that the requested speech therapy is medically necessary for this patients underlying diagnosis of autism spectrum disorder. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested Botox injections for the treatment of her chronic migraines. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for migraines, it has been shown to be effective in some patients who suffer from chronic headaches. Studies supporting this are listed above. This particular patient has failed multiple standard treatments for headaches. She has also shown benefit with Botox in the past. Botox therapy is medically reasonable and indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 38-year-old male who has hepatitis C, genotype 4C. He began combination therapy with Peg-Intron and Rebetol five months ago. The patients pre-treatment viral load was 246,000; his most recent viral load was reported as 34,940. It has been recommended that Peg-Intron therapy be continued. The Health Plan has denied authorization and coverage for continued Peg-Intron therapy on the basis it is not medically necessary for treatment of the patients medical condition.Review of the submitted records reveals that continuation of Peg-Intron therapy is not medically indicated for treatment of this patients hepatitis C. Peg-Intron therapy that does not result in a two-log drop in viral count after 12 weeks of therapy is not likely to result in clinical benefit. A study by Fried, et al. showed that only 3% of patients who did not experience a two-log drop by the end of 12 weeks had sustained viral response by the end of the treatment course. In light of these findings, there is no medical justification for continuation of Peg-Intron therapy for treatment of the patients hepatitis C virus. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computer-assisted navigation for the authorized right reverse total shoulder arthroplasty. There is a lack of mid-term to long-term quality data in current medical literature involving computer-assisted reverse shoulder surgery. Researchers note that while accurate positioning of the glenoidal baseplate in the axial scapular plane may be improved using 3D C-arm navigation for reversed shoulder arthroplasty, computer navigation may not improve the inferior tilt of the component or the position in the inferior glenoid to avoid scapular notching, and that further studies are required to confirm these findings in the clinical setting. Given that long-term clinical studies are needed to determine if preoperative planning and navigation with more precise and accurate glenoid component positioning leads to improved clinical outcomes, functional outcomes, or implant survival, there is a lack of support for the durable clinical benefit of navigated reverse shoulder replacement. Therefore, computer-assisted navigation for the authorized right reverse total shoulder arthroplasty is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested computer-assisted navigation for the authorized right reverse total shoulder arthroplasty is 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 requested service is 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 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

The parent of a 16-year-old female enrollee has requested a six month transition program for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that this patient does have a chronic illness, and she has made clear and substantial progress during the last several months. Her weight is reasonably stable. The patient has been relatively free of eating disorder behaviors. She is attending school and making plans for the future. While she continues to require psychoactive medications, her mood is good, and the patient is functioning at a reasonably high level. It is medically sound and appropriate for the patient to transfer her care from the provider to that of the Health Plan, although a transition for a full six months is not medically necessary. A transition of the patients nutritional treatment services over a one month period is medically appropriate. All remaining services, including services provided by the provider, should be transitioned over a four month period.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Final Result: Two reviewers determined that the services 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested reimbursement  breast reduction mammoplasty for treatment of her breast macromastia.  Findings:  The physician reviewer found that confirmatory evidence of symptoms such as a history of conservative therapy or physician visits for musculoskeletal symptoms are required to establish the medical necessity of mammoplasty for women with photographic documentation of smaller breasts. The submitted records do not provide adequate documentation to support the need for reduction mammoplasty in this case.
Appeal type: Urgent Care
Decision: Upheld

A 19-year-old male enrollee requested dermatological medical treatment for a dark spot on his right arm.  Findings:  The physician reviewer found that the patient presented to a dermatologist with reported dark nevi on his arm and trunk. The medical record notes that the dark nevi had been present for approximately 6 to 7 months. During this period, several lesions were biopsied which revealed some dysplasia with no significant melanocytic atypia. The documentation submitted for review does not describe any symptoms of pain, bleeding or rapid changes in the nevi. Additionally, the pathology failed to reveal a malignancy, such as melanoma or severe dysplasia.   In sum, based on the patient's clinical presentation, his symptoms would not cause a reasonable and prudent layperson to believe he or she required immediate medical attention. Thus, the patient's symptoms did not meet prudent layperson criteria for emergent care or urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female who was formerly morbidly obese. The patient reports she lost over 100 pounds by diet and exercise. The patients plastic surgeon indicates the patient weighs 180 pounds at a height of 68 inches. He has recommended bilateral brachioplasty and bilateral thighplasty. The Health Plan has denied authorization for the requested procedures on the basis they are cosmetic in nature and therefore, not medically necessary. Review of the submitted photographs and medical records from the patients primary care provider and plastic surgeon does not demonstrate the requested procedures are medically necessary. There is no evidence of any skin rash or infection on the patients arms or thigh area. Thus, there is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. In the absence of documented evidence of a functional impairment, such as a skin condition, which has failed to respond to conservative treatment, the requested procedures are not medically indicated and are cosmetic in nature. Therefore, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar fusion-single level (CPT 22558) and/or thoracic spine computed tomography (CT) (CPT 72128). Findings:  The physician reviewer found that Lumbar spinal fusion may be used for a variety of measures, including for the treatment of refractory radiculopathy in certain clinical circumstances (Wang, et al.; Watters, et al.). Lumbar fusion should be considered in patients with degenerative spinal issues after exhaustion of conservative measures, and only when such fusion is likely to result in pain relief. In this case, the patient has undergone and failed conservative measures. However, there is a lack of support for the requested single level spinal fusion procedure for treatment of this patients low back pain. The available documentation does not support that the patients condition is likely to improve with single level spinal fusion. Moreover, the records do not establish a current indication for further evaluation of the patients thoracic spine with the requested CT imaging. All told, the requested lumbar fusion-single level (CPT 22558) and thoracic spine CT (CPT 72128) are not medically necessary for evaluation and treatment of this patient.Final Result: The reviewer determined that the requested services are 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 neurological 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.