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

A male enrollee requested for Harvoni 90/400 mg tablets for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis scoreIn this case, Harvoni is indicated to potentially clear hepatitis C infection in this patient and prevent further deterioration of cirrhosis leading to decompensation and liver failure.  Therefore, the requested Harvoni 90/400 mg tablets are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old female enrollee has requested for Nexavar (sorafenib) for treatment of her glioblastoma multiforme.   Findings:  Three physician reviewers found that there are no clinical trials which have determined the utility of the combination of sorafenib and Temodar in this setting. It is not FDA-approved, compendium listed, or supported by expert consensus guidelines for this indication.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her bipolar disorder. Findings:  The physician reviewer found that the inpatient psychiatric services from the dates indicated are not supported as medically necessary for treatment of this patients medical condition. Continued inpatient treatment was not necessary given the patients non-acute and non-life threatening symptoms. Continued titration or adjustment in medications could have been done in a supervised outpatient setting. Applying the American Psychiatric Association (APA) stated that, optimal treatment setting and patients likelihood of benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment. Shader noted that most bipolar patients are treated on an outpatient basis with involvement of key relatives through cognitive behavioral psychotherapy approaches that pay attention to issues such as adherence, denial, autonomy or dependency, impact on significant others and real or symbolic losses. The author also indicated that family therapy should include a psychoeducational component, strategies to promote adherence, methods of relapse prevention, and attention to eliciting early signs of pending decompensation. All told, continued treatment from the dates indicated could have been safely provided in an outpatient setting and therefore was not medically necessary at the inpatient psychiatric level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested lipoprotein testing for evaluation of his medical condition. Findings: Three physician reviewers found that prevention guidelines for the routine use of advanced lipoprotein tests in the management of cardiac risk are limited, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. In this particular patient, previous fasting lipid studies necessitated initiation of a specific medication therapy and addition of generic medication to treat elevated cholesterol. Given the presence of known baseline coronary risk factors including hypertension, hyperlipidemia, obesity, and metabolic syndrome, this patient is already at high risk for a cardiovascular event. In this clinical setting, there was no additional diagnostic or prognostic information to be gleaned by testing for risk factors with an advanced lipoprotein test. As such, the advanced lipoprotein testing performed was not likely to have been more helpful for evaluation of this patients medical condition than other standard alternatives. Final Result: Three reviewers determined that the service 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 physician reviewers are board certified in internal medicine with sub-certification in cardiovascular disease 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg tablets.Otezla has been approved by the U.S. Food and Drug Administration and is indicated for the treatment of moderate-to-severe psoriasis. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology-National Psoriasis Foundation, patients who have psoriasis affecting between 3-10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating provider with attention paid to patient comorbidities. In this case, the patient has psoriasis affecting greater than 30% of body surface area. In this clinical setting, it is medically appropriate to continue therapy with Otezla. Thus, Otezla 30 mg tablets are medically necessary for the treatment of 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 dermatology 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 advanced lipoprotein testing for evaluation of his medical condition.   Findings:  Three physician reviewers found that current guidelines do not recommend routine use of advanced lipoprotein tests, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. A lipoprotein measure obtained from an advanced test is clinically useful if the following criteria are met: it adds to clinical knowledge; it provides risk information that is independent of established predictors; it is easy to measure and interpret in a clinical setting; it is accurate, reproducible, and internationally standardized; and it has a favorable cost-benefit ratio. Importantly, the lipoprotein measures should improve patient management, particularly through more accurate risk classification and guiding choice of therapy (Mora, et al). In this case, the patients previous fasting lipid studies showed low-density lipoprotein (LDL) and normal high-density lipoprotein (HDL) necessitating no change in statin therapy. Thus, the patient already had well controlled lipid levels and the results would not have altered therapy. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested  speech therapy services and occupational therapy for treatment of the enrollees autism and speech and language delay.  Findings:  The physician reviewer found that the medical communitys standard of practice is to provide speech therapy to autistic children. Myers and colleagues found, People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. In light of the available scientific data, speech therapy at the requested frequency is medically necessary for treatment of the patients medical condition.With regard to the requested occupational therapy, Pfeiffer and colleagues compiled an extensive meta-analysis of the medical literature and concluded that occupational therapy is effective in reducing many of the unwanted mannerisms associated with autism. Additionally, May-Benson and colleagues performed a meta-analysis of 27 journal articles utilizing sensory integration occupational therapy techniques for autistic children and concluded the therapy was effective. Given the patients documented diagnosis and associated deficits, occupational therapy at the proposed frequency is medically necessary. For the reasons set forth above, it is medically necessary that this patient receive speech therapy and occupational therapy at the requested frequencies. Specifically, speech therapy services 2 times per week for 16 weeks and occupational therapy services up to 3 times per week (24 visits) in 15 minute increments are medically necessary.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 17-year-old female enrollee has requested the enrollees participation in a wilderness program, psychological testing, escort transportation services and admission to a treatment program.  Findings:  The physician reviewer found the patients condition did not meet criteria for emergency psychiatric care. The evidence does not demonstrate the patient was a danger to herself or others nor the patient was incapacitated that she was immediately unable to provide for, or utilize, food, shelter, or clothing. Although the patient was reported to have engaged in some threatening behaviors, there is a lack of evidence that she was unable to control her actions or was likely to act on such threats. Moreover, she had no major medical co-morbidities and was not in a withdrawal state such that she was unable to care for herself. As such, the patients condition did not meet criteria for emergency psychiatric care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the IgG testing (CPT code 83516). As noted in the current peer-reviewed medical literature, this panel of laboratory testing is important in the diagnosis of myopathies and myositis. These tests can help facilitate a treatment pathway by diagnosing the various phenotypes associated with these diseases. In this clinical setting, the test was recommended to help establish the patients form of myositis. The provider noted that Raynauds is not the patients primary diagnosis. Thus, the IgG testing (CPT code 83516) was likely to be more beneficial for further evaluation of the patients medical condition than any available standard testing.One reviewer found that the IgG testing (CPT code 83516) was not likely to be more beneficial for further evaluation of the patients medical condition than any available standard testing.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certifications in pulmonary disease and critical care medicine and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an applied behavioral analysis (ABA) aide in school services. Findings:  Three physician reviewers found that the requested services are medically necessary for treatment of the patients medical condition. An ABA aide in the classroom can be highly successful. In this case, an ABA aide in the classroom is medically necessary to assist with the patients transition to the next grade level. Moreover, the occupational therapy report indicates that the patients interpersonal skills are limited. An ABA aide to assist the patient in the school to help with his social skills is medically necessary. 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: Two reviewers are board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology 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.
Appeal type: Medical Necessity
Decision: Overturned

A patient has requested authorization and coverage for Amitiza. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients irritable bowel syndrome with constipation. The submitted documentation supports the medical necessity of the requested medication. The use of an osmotic laxative (Miralax) has not been successful for this patient. The American Gastroenterological Association states that the first line of therapy should be an osmotic agent, and then another type of laxative, such as a stimulant laxative, should be tried before a newer agent such as Linzess or Amitiza is considered, as the newer agents have more adverse effects. In this case, a stimulant laxative (senna) was not effective, and an osmotic laxative (Miralax) was not effective. The records indicated that Amitiza has been effective for this patient. There is sufficient support for the requested medication in this clinical setting. For these reasons, Amitiza 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for intraoperative radiotherapy, procedure 77469. The enrollee had a screening mammogram which showed clustered microcalcifications in the superior region of the left breast. She had a diagnostic mammogram, confirming microcalcifications in the left breast measuring about three millimeters. A core biopsy showed ductal carcinoma in situ, high grade, estrogen receptor (ER) positive, and progesterone receptor (PR) positive. A magnetic resonance imaging (MRI) scan showed an oval mass measuring three millimeters in the left breast upper hemisphere at 12 oclock. A diagnostic mammogram and ultrasound showed a nodule measuring five millimeters in the left breast at 12 oclock correlating to the MRI nodule on outside imaging. There was also a second nodule at 11:30 oclock that did not correlate. The biopsy of the second nodule in the left breast showed fibroadenoma. By her imaging studies, she appeared to have a less than one-centimeter tumor; non-palpable. Her radiation oncologist noted the enrollee would be a candidate for treatment with intraoperative radiation therapy (IORT) under the clinical protocol. The enrollee chose to proceed with IORT. Peer-reviewed literature supports the use of IORT for this enrollee. Those with low-risk ductal carcinoma in situ were categorized as suitable. Two randomized intraoperative radiation therapy trials for early-stage breast cancer were recently published. With 29 months of median follow-up the results of IORT with 50-kV devices are promising as data from accelerated partial breast RT. Professional guidelines suggest that more breast cancer individuals can benefit from accelerated partial breast irradiation (APBI), including younger enrollees and those with low-risk ductal carcinoma in situ (DCIS). Those age 50 or older should be considered suitable for APBI; those age 40-49 who meet other pathologic suitability criteria should be considered cautionary; and those younger than 40 or those who do not meet the pathologic criteria should be considered unsuitable. The definition of low-risk DCIS includes screen-detected disease, low to intermediate nuclear grade, tumor size 2.5 cm and surgical resection with margins negative at 3 mm. This enrollee meets the guidelines for partial breast irradiation and IORT.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: 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.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for Lyrica for treatment of his seizure disorder. Findings:  The physician reviewer found that Lyrica is approved for adjunctive treatment of partial onset seizures. Evidence has not been provided to support the position that Lyrica is preferable to gabapentin due to greater safety, tolerability or efficacy. Due to the absence of data to support this claim, a trial of gabapentin would be reasonable.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male enrollee has requested for intravenous sedation during dental treatment for treatment of his gag reflex.  Findings:  The physician reviewer found that the patient does have a history of panic disorder and is under psychiatric care for his condition. However from the patients dental history, he has tolerated invasive dental procedures without sedation and related difficulty during these procedures. Performance of sedation is not without risk and the American Dental Association (ADA) mandates that sedation be limited to patients who require that modality.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a five-year-old male enrollee have requested for speech therapy four times per week for nine months for treatment of the enrollees autism. Findings:  The physician reviewer found that speech therapy is a recommended treatment for autism.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C.   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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, should be treated with Mavyret,  for eight weeks. these guidelines  reduced survival with delayed treatment. For these reasons, Mavyret  for eight weeks is medically necessary for this patient.Final Result: The reviewer 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 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the quantitative sensory testing.Findings:  Two physician reviewers found that although quantitative sensory testing is not  frequently utilized, there is sufficient support in the peer-reviewed literature supporting this testing in this clinical setting. Quantitative sensory testing was indicated for this patient due to findings on examination that were not consistent with usual findings of neuropathy. Given the patients presentation of possible non-organic features, the quantitative sensory testing was helpful in coming to diagnostic conclusions that will potentially guide his treating physicians. Final Result: Tworeviewers determined that the testing 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 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.