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

A male enrollee requested Harvoni for treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, patients, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Therefore, this patient should be approved for Harvoni to prevent further progression of fibrosis to cirrhosis, and to prevent further worsening of thrombocytopenia due to underlying HCV. For the reasons provided, the request for Harvoni is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi for treatment of her hepatitis C.  Two physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Treating patients with early stage disease may avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.  All told, Sovaldi is medically indicated for the treatment of this patient.   Final Result: Two reviewers 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees risk for heart disease. Findings:  Three physician reviewers found that there is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated the use of advanced lipoprotein testing  for the evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the American College of Cardiology (ACC) guidelines do not support its use for the assessment or management of cardiac risk. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. According to the ACC, there is a lack of data to support the superior benefit of advanced lipoprotein testing over the basic lipid profile. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. For these reasons, the advanced lipoprotein testing was not likely to have been superior over the standard testing options available for evaluating this patients medical condition. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of a patent foramen ovale (PFO) using a cardiac occlusion device. Hara notes that patients with PFO should undergo evaluation by both a cardiologist and a neurologist. Messe and Brecker report that PFO closure may be indicated in certain patients with a history of prior stroke. In this case, the submitted records did not include a neurology evaluation, or of clinical or radiographic evidence of a prior stroke. Therefore, transcatheter closure of a PFO using a cardiac occlusion device is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested transcatheter closure of a PFO using a cardiac occlusion device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: A patient has requested reimbursement for the substance abuse residential treatment center services provided. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The medical guidelines for substance use disorders recommends that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills, and drug-free social supports to maintain abstinence in an outpatient setting. In this case, the patient required a safe and stable living environment in order to develop recovery skills. The patient required residential or inpatient treatment consistent with ASAM level III treatment at least i.e., residential or inpatient treatment similar to what patient received. Patients conditions can wax and wane. Relatively positive documentation by one person on one day does not indicate a miraculous cure or that a patient is in the clear; it simply denotes progress and that treatment is working, which is an indication to continue, not cease treatment. Following detoxification treatment, the standard rehabilitation program is a residential treatment, which was in accordance with generally accepted standards of medical practice, clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and was therefore medically necessary. Therefore, the substance abuse residential treatment center services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis. Findings:  The physician reviewer found that prior to performing radiofrequency neurolysis, dual diagnostic block testing is indicated. In this case, the patient has only had one set of diagnostic block performed. In addition, the requested radiofrequency neurolysis will not address the patients L5-S1 neuroforaminal stenosis.Final Result: Twp reviewers determined that the requested service is not likely to be more beneficial for treatment 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 anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser skin treatments (CPT codes 96920, 96921, and 96922).Findings:  The physician reviewer found that this atients records document trial and failure of two different topical steroids and a topical calcineurin inhibitor for at least three months for treatment of her vitiligo. In this clinical setting, excimer laser is approved as a device to treat vitiligo and has been demonstrated in the medical literature to be safe and effective. Bae and colleagues evaluated 159 patients with vitiligo and found that over 50% accomplished a 75% repigmentation when tacrolimus and steroids were used with the excimer laser. Do and colleagues reported that 56% of the 80 patients in their study with resistant vitiligo experienced partial repigmentation using the excimer laser. Given this support, the requested laser skin treatments (CPT codes 96920, 96921, and 96922) are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested laser skin treatments (CPT codes 96920, 96921, and 96922) are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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: Medical Necessity
Decision: Overturned

A 38-year-old male enrollee requested authorization and coverage of chiropractic treatment. The Health Plan denied the request indicating that the requested chiropractic treatment is not medically necessary for treatment of the enrollees back pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for breast implants removal surgery. The World Professional Association for Transgender Health (WPATH) states that medically necessary treatment for gender dysphoria includes chest reconstruction or augmentation as appropriate for each patient. Approximately 2% of transgender patients who surgically transition later detransition and some seek medical and surgical treatment to reduce gender dysphoria in detransitioning. This patient has a history of transitioning from male to female with placement of bilateral breast implants. Now that the patient has returned to living as male, he has gender dysphoria about his female-appearing breasts. Chest reconstruction is appropriate for this patient. The requested removal of implants for reconstruction of a male chest is likely to address the patients gender dysphoria related to the presence of female-appearing breasts. For these reasons, the requested breast implants removal surgery is medically necessary for treatment of this patient.Final Result: The reviewer 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: 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

The parent of a two-year-old female enrollee has requested speech and language therapy services for treatment of the enrollees delayed speech. Findings: The physician reviewer found that this patient has a significant delay in her speech development. Extensive testing by her speech therapist reported a 25 to 50% delay in speech development. The enrolle's speech is not due to a delay in intellectual development, as her tested intellect is slightly above normal.  She has an isolated speech developmental disorder which is due to delayed brain development and maturation. In the meta-analysis by Law and colleagues, the authors noted the success of speech therapy for children who fail to generate normal speech within the expected range. Cognitively normal children are excellent candidates for speech therapy (GoorhuisBrouwer and colleagues). There is sufficient support in the medical literature for the requested services in this clinical scenario. All told, the requested speech and language therapy services are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested CT scan of the head for evaluation of the enrollees headache.  Findings:  The physician reviewer found that this patient presented with new onset of headache with associated nausea, vomiting and visual changes.  Neuroimaging for patients with headaches is medically appropriate when the headaches are of new onset, when the patient is over the age of 50 and when there is nausea and vomiting associated with a new headache.  This patient meets all of these criteria.  According to the International Headache Society Classification, a patient needs to have five headache episodes prior to a diagnosis of migraine-type headache.  Using this guideline, the patient cannot yet have a diagnosis of migraines, as this was her first episode.  The diagnostic procedure at issue was medically indicated in this clinical situation.  All told, the CT scan of the head performed on the said date was medically necessary for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old male enrollee requested authorization and coverage of laparoscopic vertical gastrectomy as a first stage for the duodenal switch procedure. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees super, super obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Synvisc One injection to the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has been treated with conservative options including physical therapy, medications, including analgesics, anti-inflammatory medications, topicals, methotrexate, and bracing. The provider has recommended viscosupplementation with Synvisc One for the left knee. In this clinical setting, the requested Synvisc One injection to the left knee is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the services at issue.  A follow-up examination was indicated due to the findings seen on a previous screening examination which included breast tomosynthesis.  However, the patient did not need a repeat tomosynthesis examination since the area of concern could have been targeted with ultrasound and conventional views. The repeat tomosynthesis was not of greater value to the patient than ultrasound and two-dimensional images.  Therefore, the breast tomosynthesis screening at issue was not likely to have been more efficacious than other methods of evaluation.  Final Result: Two 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 physician reviewers are certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy. One source of medical literature has approved hyperbaric oxygen therapy for the treatment of patients with sudden hearing loss. However, another source of medical literature include salvage hyperbaric oxygen therapy plus steroids as treatment option for use within one month of symptom onset. The records provided for review document that this patients hearing loss has fluctuated with worsening hearing loss noted more than the recommendation for hyperbaric oxygen therapy. The patients condition was improved following treatment with steroid injections. The patient experienced onset of hearing loss. Subsequently, the patient reported a sudden worsening in their hearing. Based on the medical literature, the onset is well outside the timeframe for recommended treatment after onset. Researchers compared hyperbaric oxygen therapy to steroids for salvage treatment of refractory sensorineural hearing loss, found no significant difference in audiometric outcomes between the groups using hyperbaric oxygen therapy or steroid injections. There is a lack of evidence that hyperbaric oxygen therapy would be more beneficial for this patients sensorineural hearing loss than existing alternatives such as steroids, particularly given the distant onset of hearing loss and the improvement in the patients audiometric outcomes after receiving steroid injections. In summary, the requested hyperbaric oxygen therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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.