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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Mavyret 100-40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 3. The submitted documentation supports the medical necessity of the requested medication regimen. 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 should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 3 patients should be treated with Mavyret 100-40 mg (three tables daily) for eight weeks. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is medically necessary for this patient.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: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested indirect consultation for treatment of the enrollees autism and speech and language delays.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. Based on the documentation submitted, the patient is non-verbal and intellectually disabled. At the age of eight his language comprehension and expressive skill was between 6 and 8 months age equivalency. However, since the advent of a picture communication system his comprehension of language has markedly improved. Thus, a picture exchange system is the treatment of choice for this patient. According to the study by Kaiser and Roberts, speech impaired children whose parents are directly involved with the childs speech therapy simultaneously with the therapist have improved language outcomes compared with parents who are independently instructed. Thus, it is important that the patients parent receive instruction of the picture communication system.  Engaging the mother actively within the therapy and spending a few minutes of each hour in parental instruction is medically reasonable and sufficient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the residential treatment center services. The medical records indicate that on the specified date, the patient had an improved affect. He was not suicidal, homicidal or psychotic, and he retained linear thought processing. The medical records also indicate that the patient was active in treatment. His episodic thoughts of suicide had resolved. He had no behavioral problems in the program. The patient did have anticipatory anxiety as discharge approached, fearing that upon discharge he would resume feuding with his parent. However, the patients treatment plan and medication regimen was not modified due to this concern. As such, the residential treatment center services were not medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Parents of a 13-year-old enrollee requested authorization and coverage of vacuum assisted closure therapy for the treatment of open right tibia fracture.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 16-year-old female with a history of depression, cutting on herself, running away from home, arguing with her parents, drug use, and overdosing on cold medication. She was admitted to residential treatment on 10/18/04 where she remained until 12/3/04. Her diagnoses included major depression, recurrent; polysubstance abuse; and oppositional defiant disorder. She was treated with a variety of psychotherapies as well as Prozac 20mg and Trileptal 300mg and was felt to have benefited a good amount. Her psychiatrist noted on 11/26/04, no aggressive or impulsive behaviors-denies urge to use drugs-denies suicidal ideation, and noted her mood as good with congruent affect. By 11/30/04, one of her therapists noted the patient as teary but able to contain emotions. On 12/1/04, she was noted as in good mood this morning. Client is very excited about going home tomorrow. However, on 12/2/04, she was noted as very frightened to go home and not doing well. Client mentioned she feels safe at CFD, client committed to write about what her fears are of going home. With regard to her home pass, a progress note of 12/1/04 indicates her pass went well and she was able to resolve conflict with her mother by taking a self time out and journaling all her feelings. She reported that she thought about using but was able to not use on pass. Her psychiatrists note of 12/2/04 indicates, Speech and activity are unchanged. Mood is good with congruent affect. A request has been made for reimbursement for residential treatment services the patient received from 11/30/04 to 12/3/04. The Health Plan indicates the services at issue were not medically necessary for treatment of the patients condition. By all accounts, this patient was quite ill with the aforementioned diagnoses as well as an underlying borderline personality organization, and her condition warranted residential treatment. In this context, a patient should be afforded the proper opportunity to segue to outpatient treatment. The patients chart notes, for example, point to her not being entirely settled about returning home. A home pass to assess just how well she might fare was also necessary, and was obtained by 12/1/04. However, it does not seem medically reasonable to cite the patient as necessarily ready for discharge four days prior to the slated discharge simply because she was not flagrantly acting out by that earlier point. The services at issue were medically appropriate and indicated to allow the patient to transition from residential care. As such, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for treatment from a provider who is California Board Certified in both female pelvic medicine and reconstructive surgery, and obstetrics and gynecology. The records provided for review document that providers from urology and gynecology, as well as a female pelvic medicine have participated in the treatment of this patient. The providers documented a thorough review of her history, as well as comprehensive physical examinations and evaluations. The providers have established plans for ongoing care that are consistent with the patients previous successful treatment and the standard of care for her medical condition. The patient has required extensive management of her vesicovaginal fistula by urologists, as well as Botox treatment and pelvic floor physical therapy. The patients gynecologist is the appropriate specialist to monitor her for possible recurrence of her vulvar dysplasia and treatment of her vaginal atrophy and dyspareunia. A provider specializing in urology is appropriately trained to treat the patients bladder urgency issues. Given these findings, the requested treatment from a provider who is California Board Certified in both female pelvic medicine and reconstructive surgery, and obstetrics and gynecology is not medically necessary for 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for CPAP (continuous positive airway pressure) device and supplies. The Health Plan has denied this request indicating that the requested equipment and supplies were not and are not medically necessary for treatment of the enrollees sleep apnea.At issue in this case is whether the CPAP device and supplies were and are medically necessary for treatment of the patients medical condition.Continuous positive airway pressure (CPAP) is considered the treatment of choice for obstructive sleep apnea (OSA), and studies have shown that there is a correlation between patient adherence and treatment outcomes. Generally, a patient is considered `compliant` with the use of a CPAP device; if there is use on greater than or equal to 70 percent of nights for four or more hours. This is based on the threshold the Centers for Medicare and Medicaid Services (CMS) has established within a 30 day window. In this case the patient has not demonstrated compliance as is generally accepted/defined within current standards of practice/care. Rather the patient only used CPAP for four or more hours per night on less than 50 percent of nights (and even then she used CPAP for less than 70 percent of nights in total.) This is otherwise inconsistent with CPAP compliance.  Continued use of CPAP in a non-compliant patient is not otherwise consistent with the standards of medical practice. The records provided for review did not demonstrate that the patient was compliant with CPAP. Therefore, the CPAP device and supplies were not and are not medically necessary.Final Result: The reviewer determined that the requested device and supplies were not and 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 neurology with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Monovisc hyaluronan injections to the right knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A study conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. A study reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Given this support, the Monovisc hyaluronan injections to the right knee were and are medically necessary for treatment of this patients advanced osteoarthritis. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services in a proposed treatment plan for treatment of her medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The patient has a maxillofacial skeletal deformity which has resulted in a functional deficit.  Her deformity cannot be corrected with orthodontics alone.  Thus, she will require orthognathic surgery.  The proposed surgery is likely to result in improved musculoskeletal, dento-osseous and soft tissue relationships.  The proposal includes a segmental Lefort 1 osteotomy and sagittal split osteotomy of the patients mandible.  The request is also for the fabrication of two oral surgical splints and for a co-surgeon for the procedure.  The performance of a segmental Lefort 1 osteotomy and a sagittal split osteotomy of her mandible is appropriate given the patients diagnosis.  The fabrication of two oral surgical splints is also indicated for the proposed surgery.  One splint is used as an intermediate splint and the other as a final splint which allows positioning of her jaws in their appropriate position.  The patients oral surgeon has also requested the use of a co-surgeon.  Given the nature of the recommended procedure, the presence of a co-surgeon is appropriate.  All told, the requested services in the proposed treatment plan are 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 oral and maxillofacial 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for low back surgery. In this case, while the patient was documented to have low back pain, a lumbar magnetic resonance imaging (MRI) showed a widely patent canal, a small disc bulge at L1-L2 that did not affect the central canal, lateral recess, or nerve roots, and a central disc herniation at L5-S1 that did not cause any canal stenosis, lateral recess stenosis, or nerve root compression. The records did not support nerve root compression at either level. Given that the records did not indicate conditions other than a minimal disc bulge at L1-L2 without central canal or neural foraminal stenosis, and that the absence of nerve root compression was a contraindication to surgery, the requested service was not medically indicated. Therefore, low back surgery was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested coverage for growth hormone therapy, Genotropin for treatment of her stated diagnosis of adult growth hormone deficiency. Findings:  Two physician reviewers found that this patient has no documented pituitary disease.  It is unclear why the IGF-1 level was done.  Stimulation tests for growth hormone are more likely to give false positive results in obese patients.  The Endocrine Society Clinical Practice guidelines do not list arginine alone as a preferred test.  Two stimulation tests should be required in this case. In this patients case, growth hormone (Genotropin) is not likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for H.P. Acthar Gel 80 Unit/mL (2 x 5 mL vials), one per day, for 10 days. The records document that this patient has spastic paraparesis and is experiencing an exacerbation of her relapsing-remitting multiple sclerosis (RRMS). Her provider has recommended a course of treatment with Acthar Gel. The U.S. Food and Drug Administration (FDA) has approved Acthar Gel for the treatment of RRMS exacerbations. The requested course of Acthar gel is clinically indicated in this patient based the current FDA approval. Given this support, the requested H.P. Acthar Gel 80 Unit/mL (2 x 5 mL vials), one per day, for 10 days, is medically necessary for 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested endovenous ablation therapy for the treatment of her varicose veins. Findings:  The physician reviewer found that this patient has severe reflux to her mid and distal greater saphenous veins. She has undergone a trial of conservative therapy (compression stockings) without relief. Based on the clinical findings and the failure of conservative treatment, she is an appropriate candidate for endovenous ablation therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal chromosomal microdeletion genomic sequence analysis (CPT code 81422 fetal chromosomal microdeletion(s) genomic sequence analysis) for evaluation of the enrollees pregnancy. Findings:  Three physician reviewers found that According to the American College of Obstetricians and Gynecologists (ACOG), cell-free DNA screening currently gives information about the three most common aneuploidies and about fetal sex but does not typically provide information about other aneuploidies. In addition, ACOG cautions that cell-free DNA screening tests for microdeletions have not been validated clinically and are not recommended at this time. 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: One physician reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine and is actively practicing. One physician reviewer number  is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and is actively practicing. One physician reviewer is board certified in obstetrics and gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System will be utilized. This is an accepted, national standard for determining the appropriate level of care for adults.  In terms of risk of harm, the records support a score of 2. There was no documentation of prior suicide attempts, and the patient did not have any suicidal ideation. With regards to functional status, the records support a score of 3.  The documentation indicated moderate impairment. It appeared that the patients alcohol use was having a significant deterioration in his ability to fulfill his responsibilities. In terms of medical/addictive/psychiatric comorbidity, the records support a score of 3.  The patient has alcohol use disorder and depression. The patients recent substance use has had detrimental effects to the patient. With regards to recovery environment, the records support a score of 3. The patient has a moderately stressful environment.  In terms of level of support, the records support a score of 3. It appears that the patients wife is supportive of the patient, but their relationship has been strained by the patients substance use. With regards to response to treatment and recovery, the records support a score of 3.  The patient had a history of various periods of sobriety in the past. His longest period of sobriety was 16 months. In terms of engagement and recovery status, the records support a score of 3.  The patient had limited engagement and recovery.  The patient participated in treatment but seemed to lack confidence to change despite intentions to do so. Thus, the records support a total score of 20.  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 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.