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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to the 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 non-liver-related conditions. The guidelines also recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. The U.S. Food and Drug Administration (FDA) prescribing information reports that a patients ALT may rise over five times the upper limit of normal in 1% of patients during Zepatier therapy, and discontinuation can be considered if the rise is greater than 10 times the upper limit of normal. However, elevated ALT at baseline is not a contraindication to Zepatier, per highlights of prescribing information. For these reasons, Harvoni for eight weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen, without trial and failure of Zepatier, 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computer-assisted surgical navigation during the left hip arthroplasty performed at a hospital. Current medical literature does not endorse significant ultimate outcome differences in functionality and/or pain reduction with hip replacement using computer-assisted navigation over a standard procedure. In a randomized controlled study of 60 patients, researchers concluded that computer-assisted surgery used for cup placement did not confer any substantial advantage in function, wear rate, or survivorship at ten years and that future studies were needed to identify what clinically relevant advantages computer-assisted surgery offered, if any, to justify its continued use in total hip arthroplasty. In a comparison of robotic-assisted and conventional acetabular cup placement in total hip arthroplasty, researchers reported that while radiographic improvements were noted, it remained to be seen if these would translate into clinical benefits for patients such as reductions in component impingement, acetabular wear, and prosthetic dislocations, or in terms of improved longevity. In this case, the patient presented to her provider with a history of pain and discomfort of the left hip, rated at nine-and-a-half out of ten. The patient reported constant sharp, aching, throbbing, shooting, and incapacitating pain. An x-ray showed severe end-stage arthritis of the left hip. While hip replacement was recommended, there is a lack of sufficient high-quality clinical outcomes reported in the current peer-reviewed medical literature to support the use of computer-assisted navigation during the procedure. Therefore, computer-assisted surgical navigation during the left hip arthroplasty performed at a hospital was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the computer-assisted surgical navigation  during the left hip arthroplasty performed at a hospital was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with a closed fracture of the left proximal tibia, resulting from an accident. The patient was initially treated by splinting and observation for compartment syndrome. An evaluation revealed persistent swelling; therefore, application of a long leg cast was not recommended at that time. A few days later, the patient returned to the emergency department for removal of the leg splint and application of a long leg cast. Physical examination findings indicated good circulation and neurological function. X-rays showed mild displacement and mild angulation at the fracture site. At issue in this case is whether services provided were emergency medical services. Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition manifests 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 placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The patient sustained an acute mildly displaced and angulated fracture of the proximal tibia. Concern for compartment syndrome was noted due to the swelling. A splint was applied and casting was delayed to prevent complications. Three days later, persistent swelling was reported. Six days post trauma, swelling had decreased and the leg splint was removed with application of a long leg cast. In this case, it was unknown if there would be any skin issues, swelling, or pain during the procedure that may have necessitated administration of conscious sedation, or fracture issues on the x-rays that may have necessitated a closed reduction. An evaluation revealed persistent swelling; therefore, application of a long leg cast was not feasible. Thus, the patient returned for removal of the leg splint and application of a long leg cast. The patients medical condition was of sufficient severity such that the absence of medical attention would reasonably have been expected to result in serious dysfunction to the patients leg. Therefore, the services provided were emergency medical services.Final Result: The reviewer determined the patient did receive emergency medical services on the dates of service at issue. 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

The patient has requested reimbursement and prospective authorization and coverage for substance abuse subacute rehabilitation residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the patient meets the six ASAM criteria for treatment at the RTC level of care. Accordingly, the substance abuse subacute rehabilitation RTC services were and are medically necessary for treatment of this patient. 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 psychiatry with subspecialty certification in addiction 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

The patient is a 49-year-old female with a history of depression and generalized anxiety disorder, inclusive of low energy, loss of appetite, crying spells, poor concentration, loss of pleasure, periods of hopelessness, and withdrawal. She was previously unresponsive to courses of Zoloft, Prozac, Celexa, Lexapro, Effexor, Remeron, Desyrel, Doxepin, and Wellbutrin. She also suffered from significant sleep disturbance with sleep interruption, restless legs, and inability to stop thinking. She either did not respond to the aforementioned medications or had side effects she found intolerable. Her psychiatrist eventually tried her on a combination of Prozac 20 mg and Provigil 200 mg in November 2003 and the patient reported feeling happier and more productive by her next visit of 12/16/03. By her next visit of 1/20/04, the patient noted that her mood was better, sleep was fair but she doesnt stress about it and she wanted to travel more. This improvement appeared sustained such that by her next visit of 2/17/04, she was noted as more available for new experiences with little severe insomnia and her feeling clear headed most of the time. By her visit of 5/18/04, she was noted as still sleeping better and less depressed, cited as feeling like her normal self again.The information submitted demonstrates the patient not only responded to the combination of Prozac and Provigil but the improvements themselves were sustained over months. To the extent the benefit of this therapy exceeded that which she experienced with other antidepressants, in conjunction with there being support in the literature for utilizing Provigil as an antidepressant adjunct, it must be concluded that Provigil is medically necessary for treatment of the patients depression. Therefore, I have determined that the requested medication is 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 patients parent has reimbursement for residential treatment center (RTC) services. Applying CALOCUS, this patient presented with some risk of harm (score 2). The medical records indicate that the patient was not actively suicidal at any time, but did have a history of speaking of suicide without past attempts. There was no indication that the patient was aggressive at any time. The progress notes did not indicate any active self-harm behaviors or homicidal ideation. The patient demonstrated mild functional impairment (score 2) as he showed significant improvement in function following a period of deterioration. He did not exhibit any significant behavioral problems, mood symptoms, or anxiety symptoms. The patient did not have any documented comorbidities (score 1). The records did not report any active medical problems or substance use. The patient did not express any symptoms of psychosis. There was no indication the patient had any medical issues affecting treatment. The patients recovery environment was mildly stressful (score 2), as there was no indication of an unsafe home environment. The patients recovery environment was supportive (score 2). The patients family was described as actively involved in treatment on a regular basis. The patient demonstrated moderate response to treatment (score 3). The providers noted that the patient was engaged well at the RTC and his symptoms were under good control with minimal mood and anxiety issues. The patient was constructive (score 2) while at the RTC and was cooperative in therapy. The patient was engaged in individual therapy and family sessions. The patients parent was constructive in treatment (score 2). The patient and his family participated in family therapy, home passes and appeared to have a working relationship. The records state that the patients parent worked actively and constructively with the providers on a regular basis. This gives the patients presentation a composite score of 16, which correlates with intensive outpatient services. Given these findings, the RTC services were not medically necessary for treatment of this patient. 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 with subspecialty certification in child and adolescent 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric sleeve surgery for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not document a body mass index of 40 or greater, or a body mass index of 35 or greater with serious comorbid conditions such as diabetes, hypertension or sleep apnea.  This patients body mass index is 32.73.  Bariatric surgery is not standard treatment in this clinical setting.  Additionally, there is a lack of documentation of dietary efforts, dietary evaluation or behavioral evaluation specifically regarding bariatric surgery.  The medical evidence does not support the requested services in this patients case. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a second gastric bypass surgery for treatment of her medical condition.   Findings:  Three physician reviewers found that a review of the medical records provided indicates that this patient has already undergone gastric bypass surgery.  There is a lack of support for a second gastric bypass surgery in this clinical setting.  Perioperative compliance is essential to weight loss after Roux-en-Y gastric bypass.  Since this patient has demonstrated recurrent weight gain despite bypass, repeat bypass is not recommended by current bariatric guidelines.   Repeat bypass surgery is not standard of care and carries a high risk of dumping syndrome as well as other perioperative complications. Thus, the requested second gastric bypass surgery is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services 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:   All three reviewers are board certified in surgery and are 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

A 42-year-old male enrollee has requested for eating disorder residential treatment for treatment of his eating disorder. Findings:  The physician reviewer found that he had been quite meaningfully engaged in the treatment program and no longer exhibited symptoms of depression. The patients treatment could have reasonably transitioned to a partial hospitalization program at that time; residential treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested for lumbar artificial disc replacement surgery with the Pro Disc artificial disc for treatment of her lumbar radiculopathy.  Findings:  Three physician reviewers found that the artificial disc replacement at issue in this case is not likely to be more beneficial for treatment of the patients low back pain and radiculopathy than any available standard therapy. The ProDisc-L total disc replacement was approved by the FDA in 2006 for spinal arthroplasty in patients with degenerative disc disease. This approval was based on a non-inferiority rather than superiority study comparing 162 randomized patients treated with ProDisc-L and 80 control patients. The main conclusions of the study at 24 months noted that the overall incidence of adverse events occurring in the ProDisc-L group, the number of device-related adverse events, and the overall success rate of the ProDisc-L group was no worse than that of the control group, using FDAs criteria for overall success. The results of this trial were published in 2007, but there were issues with the reporting outcomes (Zigler, et al). Given the unknown long-term safety and efficacy of the device, in its approval, the FDA requested a post-approval study to obtain a total of five year follow-up data from all patients in the clinical study. Given the overall lack of long-term (greater than two years) safety and efficacy data, the requested surgery is not likely to be more beneficial for treatment of the patients low back pain and radiculopathy than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested MAKOplasty for treatment of her knee pain.  Findings:  Two physician reviewers found that the requested services are not likely to be of greater benefit than other available treatment options.  Although there have been randomized controlled trials demonstrating improved alignment of knee replacement components with computer-assisted surgery, there is a lack of literature demonstrating objective improvement in clinical outcomes over traditional surgical techniques.  The current medical evidence has not established that the requested services are likely to result in improved long-term outcomes.  Thus, MAKOplasty is not likely to be more effective than other standard treatment options in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has a history of BPH (benign prostatic hyperplasia). The patients symptoms include urinary hesitancy and nocturia.  The patient has been treated with Flomax but found that it was bothersome to his premature ejaculation.  His premature ejaculation has been a lifelong problem. The patient has also been treated with Rapaflo but stopped using it due to the cost; the medication was noted to improve his symptoms.  The provider recommended Tadalafil tablet 5 mg. 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 Tadalafil tablet 5 mg is medically necessary for the treatment of this patient. According to the 2021 AUA Guidelines for BPH, clinicians should offer one of the following alpha blockers as a treatment option for patients with bothersome, moderate to severe LUTS/BPH: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin.  Lerner and colleagues reported, for patients with LUTS/BPH irrespective of comorbid erectile dysfunction (ED), 5 mg daily tadalafil should be discussed as a treatment option. Wang and colleagues, in a metanalysis of nearly 4,000 patients, stated tadalafil 5 mg once daily is an effective treatment for LUTS and ED with a low occurrence of side effects. The authors also noted tadalafil was well tolerated, and few patients withdrew due to side effects.  In this case, the patient was previously treated with tamsulosin which worsened his premature ejaculation and Rapaflo which was noted to be cost prohibitive. Tadalafil for BPH is endorsed by AUA BPH Guidelines as an appropriate treatment for BPH, especially in patients who do not tolerate alpha blockers. Therefore, Tadalafil tablet 5 mg is medically necessary for the treatment of the patients medical condition. 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 urology 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 patient is a 46-year-old woman with excessive daytime sleepiness who has been evaluated by her physician and has undergone an all night polysomnogram. The results of the polysomnogram revealed mild obstructive sleep apnea. No evidence of narcolepsy was found. Provigil has been recommended by the patients sleep expert for treatment of the patients symptoms. The Health Plan indicates that Provigil is not medically necessary for treatment of the patients condition.The Health Plans denial should be overturned. The patient has failed treatment with Ritalin and Dexedrine due to side effects. In addition, there is question as to the need and efficacy of nasal CPAP for treatment of mild obstructive sleep apnea. Furthermore, Provigil is considered to have a role in the treatment of patients who have obstructive sleep apnea with excessive daytime sleepiness. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.