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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The addition of tomosynthesis has gained worldwide popularity among providers due to an associated decrease in callbacks and increase in detection of small cancers. This advantage is particularly evident in patients with heterogeneously dense tissue, such as in this case. Tomosynthesis gives providers the ability to sort out dense glandular tissue from underlying mass or architectural distortion. Thus, the addition of the tomosynthesis is likely of more benefit to the patient than digital two-dimensional mammography without tomosynthesis. For the reasons provided, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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: Reviewers 1, 2, and 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 51-year-old male enrollee requested authorization and coverage of the medication Zocor. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. 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.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline 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.  All told, the requested Harvoni is medically indicated 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. 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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. With regard to the Health Plan alternative of Viekira Pak, there are two major and two moderate drug interactions between the components of Viekira Pak and the patients prescriptions. All told, the request for Harvoni is a more appropriate treatment option for this patient given potential drug-to-drug interactions and therefore is medically necessary for treatment of the patients hepatitis C virus. 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 parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of approximately 69% with a significant impairment in speech production. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for 24 weeks for medical treatment of her hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines offer recommendations unique to patients with hepatitis C virus with decompensated cirrhosis and bone marrow suppression. The guidelines state that for patients with decompensated cirrhosis and anemia or ribavirin intolerance, daily fixed-dose combination ledipasvir (90 mg)/sofosbuvir (400 mg) for 24 weeks is recommended. All told, the requested treatment with Harvoni for 24 weeks is supported as medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-month-old female enrollee has requested occupational therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities that occur in greater frequency than in their same aged peers. As a result, the prevention of secondary disability is important. Central hypotonia slows the acquisition of gross motor and fine skills. Ligamentous laxity and decreased strength with hypotonia complicates the ability to acquire appropriate fine motor skills. Occupational therapy with early intervention services are needed for continued improvement in fine motor skills acquisition and helps to promote arm and hand movements that lay the foundation for later developing fine motor skills. Occupational therapy helps to provide initial learning steps for feeding and dressing independently. The long-term benefit of occupational therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing. This patient has identified fine motor and adaptive delays in all domains during the most recent occupational and physical therapy evaluations. She will clearly benefit from ongoing occupational therapy and it is medically necessary and a standard of care.
Appeal type: Medical Necessity
Decision: Upheld

An has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis. Findings:  the physician reviewer found that for diagnostic purposes, the National Comprehensive Cancer Network (NCCN), guidelines recommend pelvic MRI for patients with clinical T3-4 disease, or T1-2 disease with high risk greater than 10% of lymph node involvement. According to the submitted documentation, this patient does not meet the criteria outlined in the NCCN guidelines. The NCCN guidelines do not discuss MRI for radiation planning. Instead, MRI may be used to better select patients with intermediate risk cancer for single modality brachytherapy versus multimodality brachytherapy plus external beam radiation. This patient is diagnosed with low risk disease.  MRI, for planning purposes, is generally considered for more accurate delineation of the prostate, urethra and surrounding normal tissues as a result of the superior soft-tissue delineation of the prostate and adjacent normal tissue structures with MRI. With HDR brachytherapy, the urethra is well-visualized, often with the use of hyperechoic aerated gel placed within a Foley catheter that can be seen on ultrasound and the surrounding tissues are well defined with computed tomography imaging. Recent data describes the use of MRI for planning with low-dose rate (permanent seed implant) and pulsed dose rate prostate brachytherapy, suggesting that MRI improves treatment planning. However, large studies have not been performed. Moreover, the submitted documentation provides no specific rationale for why an MRI was ordered other than for planning. There were no clinical records specifically addressing the medical necessity of the requested services. As such, the medical studies do not support the use of MRI for planning and is not widely accepted as a standard.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 27-year-old male enrollee has requested the OmniPod External Insulin Pump and monthly supplies for the treatment of his type I diabetes. Findings:  The physician reviewer found that there is no evidence demonstrating that switching to a different pump will change the frequency of the patients blood sugar testing or timing of his mealtime insulin bolusing. Further, there is no reason to believe his control will improve as there is nothing in the medical literature indicating that the OmniPod pump is superior to the Medtronics pump or other standard insulin infusion pumps. While the patient may have improved ease of use with the OmniPod, there is no evidence that this will have an effect on control. The choice of the Health Plan to authorize coverage for a standard replacement insulin pump over the OmniPod system is appropriate as there is no literature supporting the position that the OmniPod system is superior to other pumps, and there is no evidence that changing pump manufacturers will improve the patients outcomes.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In this case, breast tomosynthesis detected architectural distortion. Therefore, the services at issue were 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 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. 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 nine-year-old female enrollee has requested  for Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the FDA guidelines for GH therapy for idiopathic short stature, the use of GH is indicated for those individuals who meet the following criteria: are at least 2.25 standard deviations below the mean; current growth rates are unlikely to permit attainment of adult height in the normal range; epiphyses are not closed; and diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. This patients height is more than 2.25 standard deviations below the mean. Her current growth rates are unlikely to permit attainment of adult height in the normal range. Furthermore, her epiphyses are not closed. While it is not known if a karyotype has been performed to rule out Turners syndrome, the treatment for Turners syndrome is also GH therapy per the FDA 2003 guidelines for treatment of idiopathic short stature.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of amphotericin. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic sinusitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. The proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  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 score.  The guidelines note that the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  In this patients case, Harvoni for 12 weeks is medically indicated to prevent further progression of fibrosis.  All told, Harvoni for 12 weeks is medically indicated 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein blood testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that in this circumstance primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), C-reactive protein, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland et al).  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcome benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are no controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. For these reasons, lipoprotein blood testing was not likely to be more beneficial for diagnosis and evaluation of the patients medical condition than standard modalities.   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: One reviewer is board certified in internal medicine with sub-certification in interventional cardiology and is actively practicing. Two 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 Orthovisc injections. The medical literature supports the use of viscosupplementation for osteoarthritis of the knees. A systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks.  Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, the requested Orthovisc injections are medically necessary for the 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 orthopedic surgery 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 six-year-old female enrollee has requested coverage for speech therapy services for treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that autism and the related pervasive developmental disorders are characterized by patterns of delay and deviance in the development of social, communicative and cognitive skills which arise in the first years of life.  Early, sustained intervention is indicated, as is the use of various treatment modalities, including speech-communication therapy and behavior modification. While there have been few studies offering a direct comparison of methods, it is the prevailing opinion among specialists in the field that children with autism benefit from intensive, early intervention methods which focus on increasing the frequency, form and function of communicative acts. Intervention methods that draw from a range of philosophies and make use of varying degrees of adult direction have been shown to be effective in increasing language and communicative behaviors, as noted by Paul. In practice, children with pervasive developmental disorders often demonstrate language impairments similar to those who meet the stricter research definitions of speech-language impairment. This patient demonstrates pragmatic language impairment according to testing performed and this is a well-recognized condition in autism and pervasive developmental disorder. As such, the submitted documentation establishes the medical necessity of speech therapy services in this particular setting. Therefore, I have determined that the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.