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

A 54-year-old male enrollee has requested buprenorphine SL tablet for treatment of his chronic pain and opioid dependence.  Findings:  The physician reviewer found that buprenorphine, a high-affinity partial agonist at the mu opioid receptor is approved for the treatment of opioid dependence and functions as a full agonist for analgesia and has no ceiling in terms of pain management. Buprenorphine comes in several preparations: Subutex sublingual (buprenorphine SL mono-tablet), Suboxone tablet and film strip (buprenorphine-naloxone combination), Buprenex (buprenorphine injectable) and Butrans (buprenorphine transdermal patch). Only the patch and injection forms are approved for treatment of pain. The preparation requested by the patient, (buprenorphine SL mono-tablet) is recommended only for pregnant patients and it is not approved for pain management by the Food and Drug Administration (Renner). While the submitted documentation notes concerns regarding the patients exposure to compounds that must be metabolized such as naloxone, there is no absolute contraindication to buprenorphine-naloxone combination therapy in a patient with hepatitis C. The combination tablet has the best support for co-occurring opioid dependence and chronic pain. Thus, based on the documentation provided and review of the relevant peer-reviewed literature, the requested medication, buprenorphine SL, is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 32-year-old female enrollee has requested authorization and coverage for an orthopedic specialist consultation.  Findings:  The physician reviewer found that The records document that this patient has evidence of lumbar spinal stenosis. A review of the current medical literature indicates non-operative as well as operative options for this medical condition. A consultation with an orthopedic surgeon is indicated to discuss treatment options focusing on non-operative options first. Based on the magnetic resonance imaging (MRI) scan findings and lack of documented response to medication, the request for an orthopedic consultation is medically necessary for evaluation and management of this patients chronic low back pain and spinal stenosis.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a nine-year-old male enrollee has requested deep brain stimulation (DBS) using interventional MRI technique/ClearPoint software (performed by a pediatric neurosurgeon) for treatment of the enrollees DYT1 positive primary generalized dystonia. Findings:  Three physician reviewers found that the requested referral to a pediatric neurosurgeon for DBS is likely to provide this patient with an improved health outcome beyond that attainable with other standard interventions. Moreover, use of the interventional magnetic resonance imaging (IMRI) with ClearPoint software should facilitate electrode placement, thereby decreasing operative time, which also assists in maintaining the patients sedation during the procedure. Thus, utilization of ClearPoint software during the DBS is likely to confer significant added benefit in this patients case. All told, the requested procedure should be approved in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested weekly individual speech therapy and weekly group speech and language therapy for treatment of the enrollees pragmatic language disorder.  Findings:  The physician reviewer found that Social (pragmatic) language disorder is a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). It is similar to autism spectrum disorder without the repetitive behaviors (Brukner-Wertman, et al). Social skills groups or group speech therapy is the recommended treatment for pragmatic language disorder. There is sufficient peer-reviewed literature supporting group speech therapy for the diagnosis of pragmatic language disorder. Therefore, in this case individual speech therapy has not been established as medically necessary, however weekly group speech and language therapy is medically necessary for treatment of the patients pragmatic language disorder.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the gene testing panel performed .Findings:  The physician reviewer found that current evidence does not support the use of genotyping when choosing a neuropsychiatric medication and even less is understood about its use in the treatment of anxiety disorders. In this patients case, genetic testing was requested following failure of at least one neuropsychiatric medication. However, the medical records do not include documentation of the patients symptoms, medications and dosages attempted, length of treatment, augmentation strategies, side effects experienced, or participation in psychotherapy. It is also unknown if she had comorbid medical conditions, which may affect drug metabolism. The testing includes charts which show specific medications under the categories of antidepressants, anxiolytics, and stimulants. The charts provided showed the different transfer system gene results, therapeutic implications, and clinical impact. The fact that any one of these results shows up on genetic testing has not been shown in the medical literature to be more or less effective than another. All told, the gene testing panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1, 2 & 3 are board certified in psychiatry 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: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested a 12-week course of Sovaldi (sofosbuvir) 400 mg in combination with Ribasphere Ribapak (ribavirin) 600 mg for medical treatment of the enrollees chronic hepatitis C genotype 2.  Findings:  The physician reviewer found that The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines allow for a delay in treatment for some patients with documented early stage fibrosis, because waiting for future highly effective, pan-genotypic, DAA combinations in interferon-free regimens may be prudent. However, this patient has no contraindication to interferon-based treatment and is motivated to begin therapy to prevent further progression of disease. As referenced by the guidelines, Sovaldi 400 mg daily combined with weight-based ribavirin to treat HCV genotype 2 treatment naive patients has provided improved health outcomes (Lawitz and Gane). The study by Lawitz and Gane reported a sustained viral response (SVR) of greater than 94% in patients who received Sovaldi plus ribavirin. All told, the requested medication combination consisting of a 12-week course of Sovaldi (sofosbuvir) 400 mg in combination with Ribasphere Ribapak (ribavirin) 600 mg is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screeningFindings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  On 6/6/16, she underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. Her breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed on 6/6/16. Per the Health Plan, the service at issue was 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, she has breasts that have been described as being heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, 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.  Final Result: 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 overturned. Credentials/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.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Xifaxan (rifaximin) 550 mg three times per day for 21 days, or in the alternative, any duration of treatment with Xifaxan 550 mg three times per day. The records provided for review demonstrate that this patient has SIBO. Xifaxan has proven highly effective in SIBO for eradication of bacteria and symptom relief. Studies have shown that Xifaxan is more effective with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, fluoroquinolones, and penicillin. The dose and duration of 550 mg three times daily for 14 days is consistent with regimens used in studies, which vary widely, but are generally 7, 10, or 14 days in duration. For these reasons, the use of Xifaxan 550 three times daily for 14 days is medically necessary for the treatment of this patients SIBO. Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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 laboratory testing (genetic or chemical) Findings:  Three physician reviewers found the current literature fails to demonstrate the superior effectiveness of the services at issue. Mild cognitive impairment is a diagnosis made on clinical findings. Patients with mild cognitive impairment have a significantly increased likelihood of conversion to dementia at the rate of 10 to 15% per year. Per the medical evidence, no reliable clinical markers or diagnostic tests can predict the likelihood that an individual patient with mild cognitive impairment will develop dementia. Thus, laboratory testing (genetic or chemical) was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine 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: Medical Necessity
Decision: Overturned

The parents of a 14-year-old female enrollee requested authorization and coverage for admission to a locked residential treatment facility for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees symptoms consistent with borderline personality disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 64-year-old female enrollee has requested authorization and coverage for a CT Coronary Calcification (EBCT) (electron beam computed tomography). Findings:  The physician reviewer found that this patient presents with increased coronary risk and significantly elevated low density lipoprotein (LDL) cholesterol. In this circumstance, guidelines for the evaluation and management of hyperlipidemia are available, endorsed by several national organizations and do not recommend routine screening with coronary CT scans in this patient population. Specifically, in this patient, statin therapy is indicated based on clinical parameters and basic lipid analysis alone, regardless of results of coronary CT scanning results. Moreover, there is a lack of evidence of improved cardiac outcomes with the use of coronary CT scanning when compared to information obtained based on clinical risk profiling and basic lipid analysis. All told, CT Coronary Calcification EBCT is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. One reviewer found that CT Coronary Calcification EBCT is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for transcranial magnetic stimulation (CPT 90867, 90868, and 90869). While there is evidence that prefrontal transcranial magnetic stimulation (TMS) may be safe and effective in treating the acute phase of depression in patients who are treatment resistant or tolerant, current standard clinical practice is to trial psychotropic medications before proceeding with TMS. In this case, the documentation showed that the patient had tried and failed psychotherapy and only one drug, sertraline, to treat her depression. Although the provider reported the patient was nervous about trying other medications, further drug trials would be recommended prior to treatment with TMS. Therefore, transcranial magnetic stimulation (CPT 90867, 90868, and 90869)  was not medically necessary for the 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 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 the DecisionDx melanoma gene assay blood test for evaluation of the enrollees malignant melanoma on the mid upper back. Findings:  The physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma and can stratify whether a thin melanoma is high risk for metastasis or not. The patients provider recommended his tissue be sent for a test called Decision DX where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some impressive accuracy in thin melanomas like this patients. However, what to do with the results of the test are really indeterminate at this point. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Given these findings, the DecisionDx melanoma gene assay blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in dermatology and 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy. Findings - The physician reviewer found the submitted documentation supports that the requested medication is medically necessary. Published guidelines for the treatment of Hepatitis B recommend entecavir and tenofovir compared with alternatives for the treatment of chronic Hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient was taking, the Vemlidy formulation of tenofovir is effective for Hepatitis B, and is associated with a lower incidence of side effects such as osteopenia and renal disease. The requested medication is therefore recommended for the patients condition, and associated with a lower incidence of side effects. In addition, because the patients Hepatitis B is chronic and has the possibility of increased disease activity when treatment is discontinued, the present request for 12 months of treatment is appropriate. Under these circumstances, the request for Vemlidy 25 mg, once daily, for one year is medically necessary to treat 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 internal medicine, with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Radicava infusion therapy. Findings: Radicava (edaravone) has been approved by the U.S. Food and Drug Administration (FDA) to treat patients with amyotrophic lateral sclerosis. Edaravone showed efficacy in a small subset of people with amyotrophic lateral sclerosis who met criteria identified in post-hoc analysis of a previous phase 3 study. This patient is likely to benefit from the use of Radicava. There is a lack of other available therapies for the treatment of this patients medical condition. Thus, Radicava infusion therapy is likely to be more effective than other treatment options. Final Result: Two of the three physician 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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.