Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary:   An enrollee has requested sling procedure surgery for treatment of her urinary stress incontinence.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. There is lack of documentation submitted for review supporting a diagnosis of stress urinary incontinence. The urodynamic study did not reveal detrusor overactivity or leak with stress/urgency. The study suggests a high post void residual along with no detrusor function. This could be suggestive of overflow urinary incontinence with urinary retention and placement of a sling will increase outflow resistance leading to urinary obstruction. Moreover, the European Association of Urology (EAU) guidelines on urinary incontinence state, In clinical practice, it is a convention that non-surgical therapies are tried first because they usually carry the least risk of harm. They are often used in combination which makes it difficult to determine which components are effective. Per EAU guidelines conservative therapies include simple clinical intervention, behavior and physical therapies, lifestyle intervention and pharmacologic management. In this case, other than Vesicare which was noted to be helpful, there is lack of evidence showing the patient has tried and failed conservative therapy such as physical therapy. Based on the clinical documentation submitted, the sling procedure surgery is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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.
Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two rteviewers determined that the diagnostic procedure 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 reviewers are board certified in diagnostic radiology 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to standard two dimensional (2D) mammography. The addition of three dimensional (3D) breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, 3D breast tomosynthesis has been shown to improve patient outcomes in this clinical setting. Thus, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Two reviewers determined that the services at issue were 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 reviewers are board certified in diagnostic radiology 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin for 12 weeks for treatment of her hepatitis C virus. Three physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. For treatment-naive patients, therapy is recommended with Viekira Pak for 12 weeks (Class I, Level A recommendation). Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, treatment with Viekira Pak and weight-based ribavirin for 12 weeks is medically necessary in this patients case. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.
Nature of Statutory Criteria/Case Summary: An enrollee requested a power seat elevator for her power wheelchair for treatment of the enrollee, who has a history of a spinal cord injury. Findings:  The physician reviewer found that with power seat elevation, the patient would be able to adjust the seat of her wheelchair to be level with the transfer surface, to perform a level surface transfer independently with a sliding board.  Therefore, the power seat elevation feature is needed in this patients case.  This recommendation is consistent with the current standard of care in the field of rehabilitation medicine.  Customized power mobility equipment to allow independence with transfers is an appropriate practice in rehabilitation.  Because power seat elevation significantly facilitates transfers and promotes independence in this patients case, the requested power seat elevator for her power wheelchair is medically indicated. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for three months for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that since this patient is genotype 1b, as per the data from the clinical trials and American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Viekira Pak should be used alone and the addition of ribavirin is not recommended. The Health Plan has approved Viekira Pak with ribavirin. Viekira Pak and Harvoni are both considered first-line therapies with similar patient outcomes in terms of sustained virologic response. However, this patients provider has recommended Harvoni to avoid use of ribavirin. For these reasons, the requested Harvoni is medically necessary for treatment of this patients hepatitis C virus genotype 1b infection. Final Result:  Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are 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.
A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases and Infectious Diseases Society of America noted the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Initiation of treatment may avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C.  Therefore, Harvoni is medically indicated for the treatment of this patient.
A male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that based on the information provided, which includes two non-invasive assessments of liver fibrosis, the patient has minimal to no fibrosis.  This is despite having been infected with hepatitis C for many years.  He is unlikely to gain meaningful benefit from eradication of hepatitis C, and his prognosis is excellent.  This patient should have significant fibrosis in order to warrant treatment with Harvoni.  In this clinical setting, longitudinal assessments via noninvasive measures of fibrosis are medically appropriate.  All told, Harvoni is not medically indicated for the treatment of this patient.
A female enrollee requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the request for residential treatment services is not medically necessary for treatment of the patients medical condition. In reviewing the records of this case, partial hospitalization services provided previously were safe, appropriate and adequately addressing the patients needs. Thus, there is no evidence that the patient has failed a less restrictive treatment setting. Further, since there were no clinical assessments provided, making the patients current status unknown, it is not possible to assert that a higher level of care is indicated.  Therefore, residential treatment center services are not medically necessary for treatment of the patients medical condition.
A 52-year-old female enrollee has requested ziv-aflibercept (Zaltrap) for treatment of her recurrent ovarian cancer.  Findings:  Two physician reviewers found that this is a heavily treated patient with recurrent ovarian cancer. She has already received numerous chemotherapy off-label regimens since she has exhausted the standard options (National Institutes of Health). Zaltrap has been used off-label in ovarian cancer. There are phase II data that demonstrate efficacy with limited toxicity especially in the resolution of malignancy ascites. Based on this medical evidence, it is medically appropriate to treat this patient with Zaltrap. Thus, the Zaltrap provided from the time period specified and forward was and is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
A 50-year-old female enrollee requested revision of the gastric sleeve for medical treatment of her gastritis, gastroesophageal reflux disease (GERD), hypertension, and sleep apnea.   Findings:  The physician reviewer found that some patients do fail to lose or maintain weight loss following sleeve gastrectomy. Based on the documentation provided, it is not clear that this patient has been compliant with diet and activity requirements following surgery. Overall, the patient specific causes that might lead to a failure of a second operation with durable weight loss have not been addressed. Given the absence of a more thorough assessment and documentation of compliance with a diet and exercise regimen, the requested revision of the gastric sleeve is not supported as medically necessary for treatment of this patients medical condition.
The parent of a six-year-old male enrollee has requested somatropin (Genotropin) growth hormone for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on the available medical records, this patient has short stature but normal growth velocity, normal growth factors, and a normal response to provocative GH testing. There is no known morphological abnormality of the pituitary gland or midline structures. Given his age, it is too early to make a prediction of final adult height. It is difficult to distinguish whether the patients short stature and delayed bone age are due to constitutional delay or occult systemic disease. According to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient satisfies only two of these criteria, and no information is provided to document that all other systemic and nutritional causes of short stature have been ruled out. All told, there is inadequate evidence to support the medical necessity of Genotropin GH treatment for treatment of this patients short stature.
A 62-year-old male enrollee has requested a power wheelchair for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device.  In this case, the patient was assessed by a physical therapist who noted that his mobility issues could be addressed with a front-wheeled walker.  He could also use a manual wheelchair, if needed.  The patient has some mobility impairments, but the records indicate that he is a household ambulator.  Additionally, he has chronic health conditions, such as hyperlipidemia and hypertension, and would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
A 56-year-old female enrollee requested sacroiliac fusion for medical treatment of her sacroiliac joint dysfunction. Findings:  Two physician reviewers found that the clinical information submitted for review provided substantial evidence that lower levels of care intended to treat the patients sacroiliac joint dysfunction have failed to resolve her symptoms.  Per the current medical evidence, when nonoperative treatment fails, sacroiliac joint fusion may be appropriate.  This patient has received physical therapy, medication therapy, has sustained activity modification, and received sacroiliac joint injections, with no lasting relief.  In this patients case, proceeding with surgical intervention is warranted.  All told, the requested sacroiliac fusion is likely to be more effective than other treatment options.
A 62-year-old female enrollee genetic testing (Foundation One) for medical evaluation of her lung cancer.  Findings:  Two physician reviewers found that according to the NCCN guidelines, the Panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. In this case, it was under these circumstances that the Foundation One assay was ordered, and as such, its use was consistent with current standards of care and was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
A 25-year-old male enrollee requested rituximab (Rituxan) infusion for treatment of his Crohns disease and autonomic neuropathy.  Findings:  Two physician reviewers found that based on the current peer-reviewed medical literature, the requested Rituxan is not likely to provide this patient with an improved health outcome beyond that expected with standard available therapies. This patient is suspected to have autonomic neuropathy, and has a history of Crohns disease, which is an autoimmune condition. Treatment directed at Crohns has thus far not helped the patients autonomic symptoms. Rituxan has been shown of potential benefit with treatment of conditions such as chronic inflammatory demyelinating polyneuropathy (CIDP), multiple sclerosis, and myasthenia gravis. Data regarding treatment of Crohns disease with Rituxan is mixed, with some patients experiencing an exacerbation with treatment. Rituxan has also been associated with the development of progressive multifocal leukoencephalopathy. All told, the request for Rituxan is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
A 21-year-old male enrollee requested 131I- metaiodobenzylguanidine (MIBG) targeted radiation therapy for treatment of his recurrent neuroblastoma.  Findings:  Three physician reviewers found that neuroblastoma is a malignancy of childhood, with 90% of diagnoses occurring in children younger than five years of age. When diagnosed in adolescents and young adults it is often characterized by a prolonged course with use of chemotherapy. Because of the relative rarity of the disease, there are no large randomized trials that provide high-grade evidence on the most effective treatments. The available evidence indicates that radioactive MIBG is an efficacious agent, with response rates in various studies ranging from 0% to 75%. However, in this case, the patient has already responded to the treatment modality requested which provides a reasonable expectation that the treatment would work if administered again. All told, I131-MIBG targeted radiation therapy is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
A 48-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her menorrhagia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There are many medical and surgical alternatives to hysterectomy for the management of abnormal bleeding and painful periods.  These include oral contraceptives used for non-contraceptive reasons, as well as Mirena intrauterine device.   Non-contraceptive progestins can also be used.  There is a non-hormonal treatment, tranexamic acid, which is an antifibrinolytic agent that significantly reduces heavy periods when taken orally at the time of menses.  In addition, nonsteroidal anti-inflammatory drugs can be prescribed for heavy flow and menstrual cramps.  If hormonal treatments fail to control the problem, endometrial ablation is an appropriate alternative, with less morbidity than a hysterectomy.  This patient has had an incomplete evaluation of her abnormal bleeding, with an insufficient work-up to evaluate for other etiologies for her abnormal bleeding.  Per the submitted documentation, there is no record of a complete blood count, thyroid screening, or cervical cancer screening.  Various hormonal and endometrial causes for abnormal bleeding exist, and these require blood work and endometrial sampling by biopsy or dilation and curettage to assess.  All told, the requested laparoscopic hysterectomy is not medically indicated for the treatment of this patient.
A 67-year-old female enrollee requested a single photon emission computed tomography (SPECT) scan for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the services at issue were not likely to have been more effective than other available modalities.  Per the submitted documentation, the available blood and imaging records gave no indication for advanced liver disease or tumor.  Contemporary measurement of liver fibrosis is made serologically and/or by elastography.  The systematic review and meta-analysis by Singh and colleagues noted that the degree of liver stiffness, using elastography, can predict outcomes in patients with chronic liver diseases.  Per the authors, liver stiffness measurement may be used in risk stratification.  Thus, the superior efficacy of SPECT scan has not been established.
A 51-year-old female enrollee requested a brain positron emission tomography (PET) scan for medical evaluation of her neurodegenerative condition.   Findings:  Two physician reviewers found that in the medical literature, Claassen and colleagues reported that PET and 3-dimensional stereotactic surface projection  provide a useful diagnostic method to support a clinical diagnosis of primary lateral sclerosis. Studies with PET demonstrate predominant primary motor strip involvement. This pattern is illustrative of a stripe of hypometabolism. Thus, the literature does support the use of the requested PET for the evaluation of primary lateral sclerosis, looking for a stripe of hypometabolism. All told, the requested PET scan would be helpful to exclude primary lateral sclerosis in this patients condition.
A 57-year-old male enrollee requested the UroLift procedure for medical treatment of his benign prostatic hyperplasia.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other treatment options.  This patient has been diagnosed with prostate cancer.  However, the records do not document a repeat biopsy to determine if there has been any progression of disease.  Per the medical evidence, there is a lack of support for the UroLift procedure for patients with known prostate cancer.  At this time, long-term studies are needed to support the safety and efficacy of this procedure.  Thus, the requested UroLift procedure is not likely to be more effective than other available modalities.