Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam radiation therapy for treatment of her medical condition.   Findings:  Two physician reviewers found that the difference between proton and photon irradiation is that the protons stop abruptly in the tissue (Bragg Peak) so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability as it is simply another means to deliver radiation. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for sinonasal cancers as well, and proton therapy is an accepted treatment modality. While proton therapy is not an accepted standard outside of sinonasal cancers abutting critical structures or in the setting of re-irradiation of targets abutting critical CNS structures, both of these situations apply in this patients case. In general, proton therapy is more effective in sparing the normal tissues in and around the base of skull. Thus, the requested proton beam radiation therapy is likely to be more beneficial in treating this patients squamous cell carcinoma than any other available standard therapy.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment 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 radiation oncology 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 Synvisc One injections in both knees for treatment of her bilateral knee pain.  Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation (hyaluronan) injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis who failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with bilateral knee osteoarthritis, worse on the right. She has undergone two prior viscosupplementation injections with long-term pain reduction documented and ability to avoid surgery. She has failed to respond to other conservative treatment. Therefore, the requested Synvisc One injections for both knees would be considered medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested therapy 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 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Therefore, the services at issue were 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:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, residential treatment center services, on the dates at issue, were not medically necessary for treatment of the patients behavioral health conditions. Initially the patient had many symptoms that resulted in her admission, however, subsequently, she appeared to stabilize. Medications continue to be adjusted, however, none of the medication adjustments required treatment at the level of residential care. All told, the patient did not require 24 hour supervision for psychiatric treatment. There was no reasonable expectation that the patients symptoms or level of functioning would have significantly improved with residential care. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition. 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 sub-specialty 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral sacroiliac (SI) joint fusion surgery for treatment of her medical condition. Findings:  Three physician reviewers found that bilateral sacroiliac joint fusion surgery is not likely to be more beneficial for treatment of her medical condition than any available standard therapy. In this case, the patient has not had a complete SI exam. Local SI tenderness is not diagnostic of SI joint disease, nor is a single finding as a positive thrust test confirmatory of SI joint disease. There is a lack of confirmatory evidence that she has SI joint pain or that the SI joint is her pain generator. Moreover, there is a lack of large, prospective, randomized, scientific, studies that have shown the long term safety and effectiveness of SI fusion for chronic degenerative disease of the SI joint. Thus, the proposed surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  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 physician reviewers are board certified in orthopedic 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollees medical condition. Findings: The physician reviewer found that an MRI is supported if additional imaging is necessary or internal derangement is suspected. The American College of Radiology imaging criteria for non-traumatic knee pain state that the initial imaging examination for non-traumatic knee pain is radiography. An MRI examination for non-traumatic knee pain is indicated when the pain is persistent and conventional radiographs are non-diagnostic or when additional information is necessary before instituting treatment. Therefore, in this patient, the MRI is medically necessary as adjunctive diagnostically and potentially to affect treatment.  Regarding the requested knee surgery, the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for knee osteoarthritis generally recommend conservative treatment of osteoarthritis of the knee including weight loss for patients with body mass index greater than or equal to 25, self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engaging in physical activity consistent with national guidelines. The AAOS does not recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.  Peer-reviewed evidence based medical guidelines do not support arthroscopic surgical treatment of knee osteoarthritis and support knee joint replacement for select patients with severe osteoarthritis failing conservative treatment. This patient presents with a fairly recent onset of right knee pain and swelling. The clinical exam findings show a range of motion greater than 90 degrees, mild effusion, and medial joint line tenderness. However, the specific surgical procedure has not been identified in detail. Therefore, the requested right knee surgery is not considered medically necessary.  All told, the medical records demonstrate the medical necessity of an MRI for more definitive evaluation of this patients medical condition; but, the medical records do not support the medical necessity for knee surgery.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Specifically, an MRI of the right knee is medically necessary. Therefore, the Health Plans denial should be partially 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.
Nature of Statutory Criteria/Case Summary:   An enrollee has requested Provigil (modafinil) for treatment of her condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the medical necessity for the requested medication has not been established. There is a lack of a documentation describing the patients degree of fatigue, consequences of fatigue, contributing factors to the fatigue, previous therapeutic trials, and current status of the MS. Given the lack of information provided for review, modafinil is not medically necessary. 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX Anti-Reflux procedure for the treatment of his medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the data for the LINX procedure is from observational data and not from high-quality randomized controlled trials.  There is a lack of controlled data comparing the LINX procedure to a standard reflux operation, Nissen fundoplication.  All told, the LINX Anti-Reflux procedure is not likely to be more efficacious 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 physician 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 has requested Afirma Gene Expression Classifier testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the services at issue were likely to have been of greater benefit than other modalities for evaluating this patient.   Final Result: Three 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the guidelines all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physian 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 should be treated except those with limited life expectancy due to non-liver-related conditions. Per guidelines, treatment-naive genotype 3 patients should be treated with one of three regimens: Sovaldi/Daklinza for 12 weeks, Sovaldi/ribavirin with peginterferon for 12 weeks, or Sovaldi/ribavirin for 24 weeks.  Harvoni is not U.S. Food and Drug Administration (FDA) approved for treatment of genotype 3 and is not recommended by the guidelines, which note that the ELECTRON-II trial showed 64% cure rate with the requested regimen of Harvoni for 12 weeks. The activity of ledipasvir (part of Harvoni) against genotype 3 hepatitis C has been shown to be weak.  Although treatment is indicated in this case, and AASLD guidelines cite data showing increased survival with earlier treatment, alternatives for safe and effective therapy are available and recommended by AASLD. For these reasons, the requested treatment with Harvoni for 12 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 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In the last several years, there has been significant growth in the use of breast MRI.  Breast MRI has an important role in both screening and diagnostic settings.  However, from a screening perspective, there is no indication that this patient meets the criteria for being at high-risk for developing breast cancer, as defined as having a 20-25% likelihood of developing the disease.  MRI studies of the breast are highly sensitive but have a relatively low level of specificity.  The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  This patient has had stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence supporting the use of MRI as a surveillance tool rather than conventional mammography.  This patient reports severe discomfort in her left breast.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In this patients case, there is no reason to doubt the accuracy of the mammogram.  In conclusion, there is there is insufficient data to support the requested services in this patients case.  All told, the requested MRI of the left breast is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  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.