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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick for treatment of the enrollee who has a history of coronary disease.Findings:  The physician reviewer found that based on the records provided the patient has known coronary disease, intolerance to some statin medications (Crestor and Lipitor), and current use of simvastatin 20 mg/day without a documented LDL level since start of simvastatin.  In this circumstance the medical records do not confirm that 20 mg is the highest tolerable dose of simvastatin and do not document an LDL level after being stable on simvastatin.  There is also no documented trial and failure of Zetia.  While Zetia, on average, may lower LDL from 15 to 25 percent, occasionally, more dramatic lowering occurs in some individuals. Outcomes have been demonstrated to be improved with the addition of Zetia. Moreover, in this patients case, there is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. 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 cardiovascular disease 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

A 61-year-old female has requested coverage for intensity modulated radiation therapy (IMRT) for treatment of her breast cancer.  Findings:  Two physician reviewers found that the patient has been diagnosed with invasive and in situ carcinoma of the right breast. The tumor measured 1.7 cm on mammogram. A biopsy demonstrated grade 1 morphology. The tumor was estrogen receptor (ER) positive, progesterone receptor (PR) negative. A breast MRI did not reveal additional lesions.  A segmental mastectomy removed a grade 2, 1.5 cm invasive ductal carcinoma (IDC) tumor with 3 cm of high-grade ductal carcinoma in situ (DCIS).  Margins of resection were clear.  All 8 lymph nodes that were dissected were negative for tumor spread.  The patient was seen in a radiation oncology consultation following surgery, and intensity modulated radiation therapy (IMRT) was recommended.  IMRT is not standard in the treatment of breast cancer, but can be considered in some special situations (i.e., left sided breast cancer with significant heart in the field, central axis separation of 25 cm or more, adjacent previously irradiated area, etc.).  A review of the records and the colored printouts of the two treatment plans (IMRT and 3D) for this patient was completed. The patient does not meet any exceptional criteria requiring the use of IMRT in this case. Additionally, the listed dosimetric criteria do not appear to be dose limiting in any way for the 3D conformal radiation plan, as is suggested by QUANTEC, and the incremental benefits with IMRT are marginal.  The majority of data supporting breast IMRT is actually field-in-field forward planned radiotherapy, and the great majority of the supporting literature restricts treatment to tangent only or tangent like beams.  The treatment technique recommended here is arc-based IMRT, delivering radiation from 360 degrees, which has the disadvantage of being more prone to error with respiratory motion and increasing integral dose to the adjacent organs compared to the tangent or tangent-like treatment referred to above. Arc-based IMRT is generally felt to be outweighed by its disadvantages and has little support in the literature for the treatment of breast cancer. In sum, the use of IMRT in this case is not likely to be more beneficial than an optimal 3D plan (virtual wedge or field-in-field).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa with ribavirin (RBV) 1000 mg for 24 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1b. 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 specifically recommend treatment of patients with decompensated cirrhosis. The guidelines recommend that genotype 1b patients with decompensated cirrhosis who have failed an nonstructural protein 5A (NS5A) inhibitor such as Harvoni should be re-treated with Epclusa and RBV for 24 weeks, based on successful treatment in decompensated cirrhosis in the ASTRAL-4 trial, and the 97% success rate of Epclusa with RBV for 24 weeks in genotype 1b patients after NS5A inhibitor failure in a separate study. Final Result: The reviewer determined that the requested regimen 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested skilled nursing facility treatment services for treatment of the enrollees traumatic brain injury.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued skilled nursing facility treatment services has been established. In this case, the patient has severe brain injury and is in a vegetative state. Skilled nursing level care is for patients who are undergoing rehabilitation and have nursing needs. In this case, the patient has nursing needs. The patient requires monitoring in a facility with continuous pulse oximetry and registered nurses present. For the reasons provided, continued skilled nursing facility treatment services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old man who had a rise in his annual PSA from 4.2 to 5.3 in January 2006. Sextant biopsies were performed and the patient was diagnosed with adenocarcinoma in January 2006. Pathology revealed a Gleason score of 6 (3+3) in 30% of the core. The patient was offered 3D-CRT, IMRT and brachytherapy but prefers to undergo proton beam radiation therapy. He believes proton beam therapy has better cure rates and fewer side effects than conventional photons. The Health Plan denied coverage for proton beam radiation therapy on the basis that it is not medically necessary.Proton beam is a precise and conformal beam that can deliver 7800cGy to the prostate without significant radiation to the adjoining structures. IMRT is also a precise and conformal radiation beam that can deliver the same dose of 7800cGy with equally fewer side effects. 3D-CRT can deliver 7400-7600cGy to the prostate with almost equal precision. Temporary brachytherapy plus conventional or 3D-CRT radiation can deliver 12,000cGy to 16,000cGy with no more side effects or complications than IMRT.  Given the small size of the patients tumor, any of the above choices will offer him a 95% cure. There is no convincing evidence that proton beam radiation therapy is superior to other currently used forms of external beam therapy or brachytherapy.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-month-old female enrollee has requested a custom shaping cranial helmet for the treatment of the enrollees torticollis, right plagiocephaly and bilateral brachycephaly. Findings:  The physician reviewer found that this patient was born with cranial asymmetry as a result of intrauterine positioning. In addition, she experienced torticollis. She has failed standard treatment recommendations for positioning and physical therapy. The measurements taken of her head revealed a cephalic index of 98%, which is much greater than the norm and clearly representative of severe brachycephaly. Her cranial asymmetry was exacerbated by plagiocephaly, resulting in significant deformity. Based on the standard of care described above, orthotic therapy is medically necessary and appropriate for this infant to prevent future complications and permanent deformity.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for continuous glucose monitor (CGM) Dexcom G6 and supplies. CGM systems are a recent technologic development that uses interstitial glucose monitoring to display glucose concentrations frequently throughout the day. This regular surveillance allows for determinations of glucose trends and immediate feedback while omitting numerous daily finger stick blood glucose tests (Condren, et al.). According to the American Diabetes Association (ADA) recommendations, glycemic variability, evaluated by a CGM system has an important role in assessing the effectiveness and safety of treatment in many patients with type 1 diabetes (Breyton, et al.). This patient is noted to have a diagnosis of type 1 diabetes. The patient reports that multiple finger sticks per day are required to maintain insulin. The provider noted that the patient has experienced episodes of nocturnal hypoglycemia. The patients provider has recommended treatment with the Dexcom G6 CGM system and related supplies. Based on the current medical literature, the requested Dexcom G6 CGM system is appropriate, given its capabilities to reduce episodes of nocturnal hypoglycemia. All told, the requested CGM Dexcom G6 and supplies are medically necessary for the treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left ventricular assist device for treatment of the ventricular tachycardia, congestive heart failure, and hypertension. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. According to the records, the patient has severe cardiomyopathy and documented ongoing noncompliance with medication as well as ongoing drug abuse with methamphetamine. In this circumstance, documented medication noncompliance and ongoing drug abuse are established contraindications to cardiac transplantation and other device related advanced heart failure therapy. Compliance with prescribed medications and absence of drug abuse are both essential to successful management of patients with a left ventricular assist device placement.  Current guidelines endorsed by several national organizations are also consistent with this approach. Final Result: The reviewer determined that the requested device 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Remicade infusions. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Crohns disease. It has been well established that response to Remicade is more likely when serum trough levels are greater than 3 micrograms per milliliter. Below this level, both primary non-response and secondary loss of response are more common.  It is also clear that Remicade dosing requirements vary from patient to patient, and that a large percentage of children on standard dosing have inadequate trough levels.  Researchers developed a pharmacokinetic model that accurately predicts trough concentrations in children with Crohn's disease receiving Remicade. This individualized dosing strategy with plans for future dose de-intensification is more likely than standard dosing to achieve and maintain clinical remission. Here, the same dosing strategy was employed by the patients treating pediatric endocrinologist. Recent medical evidence supports this approach to treating children with Crohns disease. Therefore, Remicade infusions are medically necessary for this patient.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 pediatric 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: Medical Necessity
Decision: Upheld

A female enrollee requested authorization and coverage for a habituation device. The health plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees mild bilateral high-frequency sensorineural hearing loss and bilateral tinnitus.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Adderall for treatment of the enrollees idiopathic hypersomnia. Findings: The physician reviewer found that in this case, the generally accepted standard of practice supports the use of Adderall as prescribed for treatment of this patients idiopathic hypersomnia. According to  American Academy of Sleep Medicine guidelines, amphetamine, methamphetamine, dextroamphetamine, methylphenidate, and modafinil may be effective for patients with daytime sleepiness due to idiopathic hypersomnia (Morganthaler, et al). Central nervous system stimulants and wake promoting agents are commonly prescribed for use in idiopathic hypersomnia (Chervin; Masri, et al). For these reasons, the requested Adderall is medically necessary for treatment of this patients sleep disorder.   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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg tablet, daily for treatment of the enrollees hepatitis B.  Findings:  The physician reviewer found that There is sufficient support for the requested medication in this clinical setting. The goal of treatment is long-term viral suppression. The American Association for the Study of Liver Diseases guidelines 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 previously taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. Therefore, Vemlidy 25 mg tablet, daily is medically necessary for the treatment of this patient. 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.
Appeal type: Urgent Care
Decision: Overturned

A 32-year-old female enrollee has requested emergency services.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient had a headache that was rated at 8/10 on the pain scale. The patients pain level was of sufficient severity that a prudent layperson would have thought this to be an emergency medical condition and would have sought immediate medical attention in an emergency department. As such, the patient met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine (CPT code 72148) and/or MRI of the thoracic spine (CPT code 72146).Findings:  The physician reviewer found that records document a history of back pain with diagnoses of lumbago with sciatica. The patient has undergone treatment with medications and diclofenac gel. Prior MRI demonstrated chronic L1 compression fracture deformity with decreased in vertebral height with stable findings compared to previous imaging. The patients provider has recommended additional imaging with MRI of the lumbar and thoracic spine. According to American College of Radiology (ACR) guidelines, Imaging is usually not appropriate for the initial imaging of patients with subacute or chronic low back pain with or without radiculopathy, no red flags, and no prior management. This patients records do not include documentation of any neurological deficits, or red flag signs or symptoms to support an indication or the requested MRI scans of the lumbar and thoracic spine. There is a lack of evidence of failure of conservative therapies or surgical interventions reported in the available records. Therefore, the requested MRI of the lumbar spine (CPT code 72148) and MRI of the thoracic spine (CPT code 72146) are not medically necessary for 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 radiology with subspecialty certification 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.
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 screening.  Findings:  Two physician reviewers found that the medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. Final Result: Two 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

A 59-year-old male enrollee has requested for continued stay at an acute rehabilitation unit for treatment of his medical condition. Findings:  The physician reviewer found that the studies  do indicate improved outcomes in ARU settings as opposed to outcomes from SNF, even for older patients.