Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for treatment of the enrollees hepatitis C infection. Findings:  The physician reviewer found that According to the 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). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg is 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 reimbursement for his Oncotype Dx Prostate Cancer Assay.  Findings:  Three physician reviewers found that while the Oncotype Dx Prostate Cancer Assay has the propensity to determine the risk of recurrence and sometimes change therapeutic intervention based on risk, there is currently a lack of well designed, controlled clinical trials to demonstrate an improvement in health outcomes based on its use.  The National Comprehensive Cancer Network guidelines lists Oncotype Dx for patients post biopsy for patients with very low risk and low risk prostate cancer who did not receive therapy and are candidates for surveillance or active therapy with a life expectancy of 10 years. This patients prostate cancer was not newly diagnosed and the initial Oncotype was done in 2013. This patients progression of the Gleason score over a period of three years from 6 to 7 was enough to demonstrate progression. Thus, the Oncotype Dx Prostate Cancer Assay provided did not add any additional information not provided by the clinical situation and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for WalkAide for treatment of the enrollee, who has history of right foot drop, functional gait disorder, and pressure ulcer of the right foot. Findings: Three physician reviewers found that the requested equipment is documented extensively in the medical literature as beneficial for central nervous system neurological injuries but not for peripheral nervous system pathology. While the provider stated that WalkAide will provide dorsiflexion assistance in this patients case, the current studies are lacking.  There is a lack of peer reviewed literature to support a rationale or mechanism by which the requested treatment would be effective or operational for a peripheral nervous system lesion as described in this patients case.  In sum, WalkAide is not likely to be more beneficial than the standard treatment options for this patient.Final Result: The three reviewers determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in physical medicine and rehabilitation and are actively practicing. The reviewer 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 LINX procedure (CPT code 0392T, laparoscopic anti-reflux surgery)for treatment of his gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that the LINX device received U.S. Food and Drug Administration (FDA) premarketing approval for four years, effective 3/22/12. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. As noted by in a study, sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. This patients records support a diagnosis of GERD based on pH recording off PPI therapy, and per charted comments he has not optimally benefited from acid suppression treatment. Although symptomatic for many years, significantly he has not developed endoscopic evidence of esophagitis. From a symptomatic perspective, the patient may be considered medically refractory to acid blocker drugs. However, implantation of LINX in this patients clinical setting places him at significant risk for dysphagia post-LINX implantation given his known esophageal dysmotility. Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and is 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. The guidelines recommend several medications, but Epclusa is the most appropriate therapy in this case based on NS5A resistance testing. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewers 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 number is a 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: The parent of a child enrollee has requested 51.6 hours per month of one-on-one applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In this case, the patient demonstrates multiple problematic behaviors which include aggression, inflexibility/non-compliance and eloping. These behaviors place the patient at significant risk given her lack of awareness. In addition, the patients unwillingness to participate in low preference transitions within the community has made it increasingly difficult for her to demonstrate mastery of her adaptive skillsets and behavioral goals. Final Result: The reviewers 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Anenrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injection.  Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has lumbar radiculopathy, and the probable etiology is either scaring or recurrent disc protrusion at the site of the prior laminectomy.  However, the records do not document that he has had a recent trial of conservative therapy.  The American Pain Society recommends a trial of conservative therapy before starting interventional therapy.  Conservative therapy includes physical therapy, chiropractic therapy or a home exercise program.  All told, the requested lumbar/sacral transforaminal epidural injection is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent 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 should be treated (except those with limited life expectancy due to non-liver-related conditions), regardless of fibrosis stage.  The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed (Zepatier and ribavirin for 16 weeks).  In this patients case, NS5A resistance testing results were not provided.  For these reasons, although hepatitis C treatment is needed, Zepatier 50-100 mg, one per day for 12 weeks is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a joint jaw oral device (occlusal orthotic device).Findings:  The physician reviewer found that there is sufficient support for the device at issue in this clinical setting.  Splint therapy has been shown to be beneficial in patients with temporomandibular joint disorder and myofascial pain.  Oral devices have been shown to decrease symptoms in 70 to 90% of cases.  The majority of patients with temporomandibular joint disorder can be treated with a single stabilization splint. Final Result: The reviewer determined that the device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.  Findings:  Three physician reviewers found that the patient underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination as well as a focused hand-held bilateral breast sonogram.  The current images were compared to a prior mammogram dated 4/12/11, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being extremely dense.  Considering the palpable abnormalities and the negative results on her imaging studies, it was recommended that the lumps be managed on clinical grounds. The Health Plan denied coverage for the bilateral breast tomosynthesis portion of the examination as investigational for the evaluation of this patient.Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there are multiple reasonable indications for tomosynthesis. She has breasts that have been described as being extremely dense. It is specifically those patients who have very dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Secondly, in the clinical setting of palpable masses, it is imperative for the radiologist to be as sure as possible that there is not a radiographic correlate.Final Result: All three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary:An enrollee has requested orchiectomy and vaginoplasty/labiaplasty for treatment of the enrollees gender dysphoria. Bilateral orchiectomies and vaginoplasty/labiaplasty are part of the surgical transition process for male to female transition. Based on the medical records provided, this patient has well-documented gender dysphoria. She has previously undergone parts of gender transition with apparent success. She has been undergoing hormonal therapy and has been living as a female. Furthermore, the medical literature recommends that after a diagnosis of gender identity disorder, the therapeutic approach commonly includes three phases (triadic therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics. In this patients case, the recommended criteria have been established. For treatment of her gender dysphoria, her external anatomy should be more consistent with a female anatomy than of a male. Bilateral orchiectomy and vaginoplasty/labiaplasty are consistent with the appropriate female anatomy. The Health Plan had indicated that this patient was not compliant with treatment regimens, office visits and necessary laboratory tests. However, the submitted documentation supports that this patient has addressed these issues and her most recent office visits and therapy sessions appear consistent with the Health Plans clinical criteria. As such, the medical documentation supports the requested services in this patients case.Findings:The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the removal of tissue from the breasts performed for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. The patients pain and discomfort is not adequately supported in the medical documentation as likely due to distention and tightness from hypertrophied breast. In addition, the patients grade of gynecomastia is not adequately defined and photographs were not provided for review. The records do not demonstrate a concern for possible malignancy based on examination detail and other results. Other possible causes had not been sufficiently evaluated, including relevant laboratory studies and endocrine work-up. Therefore, the removal of tissue from the breasts performed has not been established as medically necessary for treatment of the patients. Final Result: The reviewers determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.