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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.   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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for treatment of this patients hepatitis C virus 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for an Aimovig 70 mg/mL auto-injector. Aimovig (erenumab) is a calcitonin gene-related peptide receptor antagonist (CGRP) approved by the U.S. Food and Drug Administration (FDA) for the preventive treatment of migraine in adults.  Tepper and colleagues found that in patients with chronic migraines, erenumab 70 mg and 140 mg reduced the number of monthly migraine days with a safety profile similar to placebo. Pellesi and colleagues note that dual therapy with monoclonal antibodies and botulinum toxin type A holds promise in patients with treatment-resistant chronic migraine. In this case, the patient has tried and failed Nurtec, and reports improvement on a combination of Botox and Aimovig. Given that the concurrent use of CGRP and Botox as a management option for chronic migraines is not contraindicated in current medical literature, the requested medication is medically indicated. Therefore, an Aimovig 70 mg/mL auto-injector 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on the dated of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Physician reviewers 1, 2, & 3 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. 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, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Medical Necessity
Decision: Overturned

A 59-year-old female has requested authorization and coverage for occupational therapy with a lymphedema specialist. Reviewer's Findings:The reviewing physician found that lymphedema therapy has been proven beneficial for management of volume and pain.  The patients condition interferes with activities of daily living and treatment is expected to reduce edema to a more manageable level in a reasonable period of time. The patient should receive occupational therapy evaluation and treatments until her edema is back to baseline.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene testing (DecisionDx-Melanoma Gene Expression Assay). Based on current peer-reviewed medical literature, there is a lack of scientific evidence permitting conclusions concerning the effect of genetic testing such as the DecisionDx-Melanoma Assay for use in this clinical setting. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Moreover, there is a lack of published data to support its routine use to guide treatment decisions resulting in improved patient health outcomes. Therefore, the gene testing (DecisionDx-Melanoma Gene Expression Assay) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the gene testing (DecisionDx-Melanoma Gene Expression Assay) 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 gene testing (DecisionDx-Melanoma Gene Expression Assay) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested a deep brain stimulator for the treatment of his left arm brachial plexus injury. Findings:  Two physician reviewers found that this patient has had some relief with spinal stimulation. Pain medications affect his thinking, memory and recall and thus are not a good alternative. The medical literature suggests that for select patients, deep brain stimulation (DBS) is an alternative that is likely to provide pain relief. This patient fits the profile of those likely to respond to DBS since he has benefitted from spinal stimulation in the past. Based on the evidence provided, it appears that DBS is the most appropriate option for this patient; it is within the standards of good medical practice of the neurosurgical community and likely to produce the desired benefit.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech and language therapy for treatment of the enrollees developmental delay and autism. Findings:  The physician reviewer found that deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted the better chance the young patient has for developing adequate skills to function in the community. In the published literature, Myers and colleagues noted that, Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. Children with autism have deficits in speech and language, as well as social interaction and pragmatic communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are the most appropriate providers. For these reasons, the requested speech and language therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for all or any of the requested durable medical equipment (DME) accessories (power seat elevation system (E2300) and battery (E2361)).At issue is whether all or any of the requested durable medical equipment (DME) accessories (power seat elevation system (E2300) and battery (E2361)) are medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or outside of the home, including access to the community. A power mobility device that allows for independent mobility is an appropriate and medically necessary device for individuals with spinal cord injuries according to a study. For some patients, power seat elevation can be an appropriate component for a power wheelchair in order to allow a user to independently transfer into and out of the chair according to another study. In this case, the records do not indicate the patient is able to safely and independently transfer with power seat elevation. There is no documentation of an actual transfer trial where he was able to transfer himself independently, effectively, and safely by using a power seat elevation feature or in equivalent conditions. The patients environment can otherwise be adjusted as needed to optimize his independence with respect to reach in his home. Thus, a power seat elevation is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. In this case, the records noted that the patients current power mobility device has various broken parts. The Health Plan has approved coverage for a power wheelchair. A battery is required to power the wheelchair. Therefore, the requested battery (E2361) is medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Final Result: The reviewer determined that some of the requested equipment 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 physical medicine and rehabilitation 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 44-year-old male who is requesting Provigil for excessive daytime sleepiness. He has severe obstructive sleep apnea confirmed by polysomnography. His titration study indicated effective pressures of 7cm to 9cm H2O.  The patients respiratory disturbance index (RDI) was 45.2 and he had hypoxemia with desaturations to 86%.  His sleep latency was 18 minutes, within the normal range. There is reported non-compliance with the CPAP mask preventing definitive conclusions regarding the efficacy of the therapy.   The patients request for Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.The patient clearly has severe obstructive sleep apnea as indicated by an RDI of 45.2 with associated hypoxemia. The titration study confirmed that CPAP is effective at pressures of 7cm to 9cm H2O.  At this point, the patients sleep apnea is essentially untreated due to his intolerance of the CPAP mask.  The use of Provigil in this clinical setting is not consistent with its intended usage.  The patient still has nocturnal hypoxemia and there is no control data to determine if Provigil is effective under these circumstances.   Although Provigil apparently allows the patient to function, its use is potentially harmful by facilitating a delay in the treatment of the underlying pathology. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female has requested coverage for past and future prolotherapy for treatment of her pain.  Findings:  Three physician reviewers found that the patient has a reported history of low back and right hip pain. The documentation noted sacroiliitis and right hip labral tear.  The current medical evidence has not established the superior efficacy of the services at issue in this patients case.  This patient has been diagnosed with sacroiliitis and right hip labral tear.  Prolotherapy is not an effective treatment for back pain.  There is a lack of support in the medical literature for the services at issue.  All told, the treatments provided, and future additional prolotherapy, were not and are not likely to be more efficacious than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for oximeter. The records indicate that this patient has a history of epilepsy status epilepticus. The available details of the seizures suggest that each episode involved at least five minutes of generalized tonic-clonic activity. The seizures occurred at night, during sleep, and lasted over 20 minutes. The patient also vomited during the first seizure. These features place the patient at increased risk of further life-threatening unwitnessed episodes of status epilepticus (Abdel-Mannan, et al; Keller, et al.). The patients mother has attempted use of an over-the-counter pulse oximeter, which is not remaining in place to allow for proper readings. The provider has recommended an oximeter for home use. In order to determine the value of pulse oximetry in detecting seizures, Goldenholz and colleagues evaluated 193 seizures among 45 patients. The authors found that blood oxygen saturation level (SpO2) thresholds of 80%-86% were able to detect 63%-73% of generalized convulsions and 20%-28% of focal seizures. Although routine use of at-home pulse oximetry to detect seizures is not supported in the medical literature, in this patients specific case the device is supported as medically necessary. A medical-grade pulse oximeter would alert the patients parent to seizure activity occurring during sleep, allowing intervention. The patients multiple risk factors including generalized tonic-clonic seizures with status epilepticus at night during sleep, apnea with hypoxemia, vomiting with the potential for aspiration, and obstructive sleep apnea with Pierre Robin sequence, place her at high risk of unnoticed status epilepticus. All told, the requested oximeter is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 with special qualification in child neurology and expertise in neurodevelopmental disabilities 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

The patient has requested authorization and coverage for brand name medication, Lexapro 20 mg tablet. According to the records provided for review, this patient has been stable on brand name Lexapro for over 10 years for the maintenance of her major depressive disorder (MDD). The American Psychiatric Association (APA) guidelines indicate that patients treated for an uncomplicated MDD who exhibit a satisfactory response to an antidepressant medication should continue to receive a full therapeutic dose of that agent after achieving remission in order to prevent the recurrence of mood symptoms. Generic antidepressants are the first-line of pharmacological treatment of MDD. However, this patients records document failure of two prior antidepressant trials, long-term stabilization on brand name Lexapro, and the inability to tolerate the generic version of Lexapro. Abrupt discontinuation without cross-tapering of one antidepressant medication and switching to a different generic or brand name antidepressant medication carries a risk of relapse and destabilization of the patients mental illness due to her previous history of intolerance. Therefore, the requested brand name Lexapro authorization is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 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: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested an abdominal hysterectomy for treatment of her uterine fibroid. Findings:  The physician reviewer found that the Health Plan has indicated that an endometrial biopsy to rule out endometrial pathology has not been performed. Per the American College of Obstetricians and Gynecologists, selected disorders or distortions of the uterine structure may enhance the risks associated with an endometrial biopsy or make success unlikely.  Another concern exists when areas of the myometrium are extremely thin, which may be the case in the presence of previous uterine surgery, such as cesarean delivery.  In these circumstances, there may be an increased risk of transmural thermal injury that could involve the adjacent bowel or bladder. This patients history is significant for a prior cesarean section. Additionally, an endometrial biopsy is of particular value if the menstrual pattern is that of anovulation where there is unopposed estrogen, which then increases the risk of endometrial cancer.  However, this patient has regular menses, which is the hallmark of ovulatory cycles.  She also has a normal appearing endometrial cavity on ultrasound.Although abdominal myomectomy is another option for treatment, as noted in the American College of Obstetricians and Gynecologists Bulletin pertaining to alternatives to hysterectomy, it is not definitive, may allow for recurrence, and is an option better suited to someone who wishes to preserve childbearing, which this patient does not.  All told, an abdominal hysterectomy is medically indicated for this patient. She is not an appropriate candidate for alternate conservative treatments and does not desire further pregnancies.