Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine headaches. Findings:  Three physician reviewers found that although Botox has been found to be beneficial in some migraine patients, it is not considered a first-line agent. Lewis and colleagues practice guidelines for migraine patients suggest that first-line agents should be tried prior to initiating Botox therapy. This particular patient has not been tried on many of the first-line agents for headache listed in these guidelines. Although first-line agents are limited during pregnancy, Botox has a class C pregnancy risk factor, and is not recommended by the manufacturer for use by patients who are pregnant. In sum, the records and medical literature suggest that Botox is not medically indicated or likely to be more beneficial for treatment of this patients medical condition than any available standard therapy
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for evaluation of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that the current medical evidence supports the requested medications in this clinical setting.  According to 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 life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive, genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  Delay in treatment may result in decreased survival.  All told, Sovaldi and Daklinza in the requested dosage and duration are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in 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 patient has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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: Upheld

A 61-year-old male has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that a proton is the charged nucleus of a hydrogen atom (hydrogen atom minus an electron).  Charged particles including protons and carbon can be used to deliver therapeutic radiation. Standard radiation is delivered with a linear accelerator (LINAC) which delivers photon therapy, while protons are generated from a cyclotron. The difference between proton and photon irradiation is that the protons stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue. In practice, the use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability in certain conditions such as base of skull chordomas and chondrosarcomas and pediatric tumors, due to the sharp dose fall off, allowing high dose delivery to the tumor while relatively sparing the neighboring normal tissue. The current status of the peer reviewed publications is unsettled with regard to the safety and efficacy of proton therapy in terms of outcomes when compared with conventional radiation therapy. Most providers support proton therapy as having some role in the treatment of well selected patients, including some patients with prostate cancer (Vargas, et al). The two most respected therapeutic proton facilities in the U.S. have researched the potential of proton beam therapy in prostate cancer (Zietman, et al; Slater, et al). In their 2004 paper, Slater and colleagues concluded that, Conformal proton radiation therapy at the reported dose levels yielded disease-free survival rates comparable with other forms of local therapy, and with minimal morbidity. Dose-escalation strategies are being implemented to further improve long-term results. However, the issue of whether proton therapy for prostate cancer affords any advantage over intensity modulated radiation therapy (IMRT) remains controversial. Most reports, including the article from Vargas and colleagues systematic review, assert that patients treated with proton therapy fare comparably to patients treated with IMRT. Further, the authors found that proton therapy yields improved normal tissue sparing as compared to IMRT. Of note is that other accepted technologies such as image guided radiation therapy (IGRT), with daily computed tomography (CT), imaging of fiducials or ultrasound, coupled with IMRT, also reduce normal tissue dosing and were technologies that were not investigated in that analysis. With the limited data, it is possible that proton therapy is actually disadvantageous as the depth of proton delivery is more susceptible to changes in tissue density. Thus, despite the fact that proton therapy for treatment of prostate cancer is not experimental, other treatment approaches including IMRT with or without IGRT have been proven to be highly effective and well tolerated. All told, there are insufficient compelling data to suggest that proton therapy is superior to or more beneficial than IMRT for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: Two of 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that 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 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 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: Three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee's risk for breast cancer.  Findings: Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, for this patient who had noted fibrocystic changes, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit than had the examination been done with two-dimensional imaging alone.  All told, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.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

The parent of a one-year-old male enrollee has requested for speech therapy for treatment of the enrollees delays in expressive language skills.  Findings:  The physician reviewer found that Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to a meta-analysis by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment. Based upon the medical literature, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old male enrollee requested authorization and coverage of a referral to an orthopedist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees shoulder pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 14-year-old female and the full sibling of a sister with mental retardation, dysmorphic features and congenital anomalies. The sister has a chromosomal abnormality consisting of a deletion of the short arm of chromosome #8 from p22 to p terminal. Karyotypes were performed on both of the parents using peripheral blood and no abnormalities were identified. The parents were counseled by a clinical geneticist who advised them that the healthy siblings did not require chromosomal studies since the youngest childs abnormal karyotype arose de-novo as a new mutation. Nonetheless, the enrollees parent has requested authorization for genetic testing for the patient. The Health Plan denied the request based upon a determination that the testing is not medically necessary.The patients sister has congenital heart disease, mental retardation and dysmorphic features which are compatible with her abnormal karyotype 46XXdel(8)(p22). The patients mother has a normal female karyotype in blood, 46XX, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). The patients father has a normal male karyotype in blood, 46XY, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). These normal parental karyotypes support the opinion that the youngest childs chromosomal abnormality arose as a de-novo mutation. The enrollee is a normal and healthy female without any signs suggestive of a chromosomal anomaly. Chromosomal studies are not indicated for her at this time. Based upon the information set forth above, I have determined the requested testing is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested for Lap Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that the patient does not meet the criteria set forth by the National Institutes of Health (NIH) for weight loss surgery.the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. This is particularly true for this patient, as an active infection such as MRSA is generally a contraindication to placing an implantable device.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that the use of Botox for management of headaches remains an off-label indication. However, recent publications suggest that Botox is an effective treatment for chronic migraine without medication overuse as noted by Freitag and colleagues. In addition, an article by Schim also reported that Botox is helpful in managing refractory headache syndromes. These publications are consistent with this patients positive response to prior treatment with Botox.
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 is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. 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. Accordingly, the digital breast tomosynthesis performed on 10/10/16 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 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. Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology 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: Upheld

A 53-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Decision Dx Melanoma blood test for evaluation of the enrollees melanoma. Findings:  The physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such at the Decision Dx Melanoma Gene Assay should not be used outside of clinical trials. Moreover, the testing at issue is not the standard of care in melanoma treatment. For the reasons provided, the Decision Dx melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni. These recommendations are based on multiple randomized clinical trials. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. However, while treatment naive patients with viral loads less than 6,000,000 IU/mL can be treated for weeks, this regimen is not appropriate for patients who have previously failed therapy. In this patients case, the provided records do not report whether there has been hepatitis C treatment, and if so, which treatment was used. For these reasons, the requested treatment with Harvoni is not supported as medically necessary for the treatment of the patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.