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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza with Sovaldi for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that 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.  American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines also recommended 12 weeks of Sovaldi, ribavirin and peg-interferon.  The Health Plan has offered coverage for Sovaldi, ribavirin and peg-interferon.  In this patients case, the alternative offered by the Health Plan is an appropriate regimen.  Therefore, Daklinza with Sovaldi for 12 weeks are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medications are 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.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 10-year-old female enrollee requested authorization and coverage of continued occupational therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees generalized epilepsy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested therapy, once per week (code 90834) for medical treatment of his social anxiety disorder.  Findings:  The physician reviewer found that the patient has requested weekly psychotherapy.  The requested service is recommended by the peer-reviewed literature.  The requested service is safe, appropriate and consistent with good medical practice.  The frequency of the service is within typical practice standards.  It is reasonably expected that this patient may benefit from the intervention.  All told, the requested therapy, once per week (code 90834) is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested Avastin, paclitaxel and carboplatin for the treatment of his malignant melanoma.  Findings:  Two physician reviewers found that an abstract presented at the American Society of Clinical Oncology conference this year involved the use of carboplatin, paclitaxel and bevacizumab in 20 patients with metastatic melanoma. There was one partial response among all of the study participants. Although moderate effectiveness had been demonstrated with carboplatin and paclitaxel in the treatment of metastatic melanoma, there is no data indicating the addition of Avastin is useful. Thus, the proposed therapy offers no proven clinical advantage.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  During the dates of services in dispute, the patient was practicing being out of the treatment setting.  It is not uncommon to provide day passes to patients in this clinical setting to ensure they do well prior to discharge back to the community and engaging the patients in a lower level of care.  In this case, the patient had longstanding self-image beliefs which needed to be rectified and worked through while maintaining appropriate weight gain as well as ensuring stability of vital signs.  The current medical evidence supports the services at issue in this patients case.  Therefore, partial hospitalization services were medically indicated 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: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested continued occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the requested occupational therapy services are medically necessary for this patient. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including occupational therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process.  As such, occupational therapy for this patient at the frequency requested is necessary to reduce the physical and mental effects of autistic spectrum disorder and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested a 12-week course of Sovaldi 400mg and Ribapak 600/400mg for medical treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination.  In this case, the patient likely has advanced fibrosis and has cryoglobulinemia.  The recommended first-line treatment in this clinical setting includes sofosbuvir (Sovaldi).  Data from genotype 4 patients is favorable, and sofosbuvir is known to be pan-genotypic.  All told, the requested 12-week course of Sovaldi 400mg and Ribapak 600/400mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the lower back for evaluation of his back pain. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The clinical documentation submitted for review does not demonstrate that the patient has been treated with a trial of physical therapy. In addition, the documentation submitted for review does not demonstrate the patient has unequal reflexes on physical examination or has one-sided weakness. Based on the medical literature and clinical documentation provided, the request for MRI of the lower back is not medically necessary for evaluation of the patients medical condition. 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 diagnostic radiology with sub-specialty certification in interventional radiology 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

The spouse of a 40-year-old female enrollee has requested for intravenous (IV) Rocephin infusions and home health nursing visits for treatment of her Lyme disease. Findings:  Two physician reviewers found that there is no documentation in the literature advocating the use of intermittent IV antibiotic therapy for the treatment of chronic Lyme disease.  To date, the use of chronic antibiotic therapy for the treatment of a post-Lyme syndrome remains unproven.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested a consultation for bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested service. Bariatric surgery is indicated for patients with a BMI of 40 or above, or a BMI of at least 35 with severe co-morbid conditions. This is part of standard guidelines such as the NIH consensus guidelines for bariatric surgery. The submitted medical records do not document the presence of morbid obesity with a BMI of 40 or above or clinically severe obesity with a BMI of 35 or above with serious co-morbid conditions such as diabetes, hypertension, coronary artery disease or sleep apnea. Thus the request for a bariatric surgery consultation is not clinically indicated at this time. All told, the medical necessity of the requested service has not been established.
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 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.  As noted by researchers, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  It is specifically 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.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Three reviewers determined that the services at issue were likely to be more evaluation for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether interspinous and interlaminar stabilization/distraction devices (spacers)are likely to be more beneficial for treatment of the patients condition than any available standard therapy. His symptoms have included ongoing pain in the back with radiation to the lower extremity associated with numbness and weakness in the lower extremities. He has failed at least six months of conservative treatment with non-steroidal medications, opioid pain medications, physical therapy, epidural steroid injection, and bracing.Two out of three physician reviewers four that nationally recognized evidence-based medical guidelines do not recommend the use of interspinous decompression device over decompression surgery (laminectomy), the gold standard for lumbar spinal stenosis. Current evidence-based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this patients medical condition. There is no discussion relative to why this patient would not be indicated for standard decompression surgery, other than his preference to avoid invasive surgery. Additionally, Food and Drug Administration (FDA) criteria have not been met for the use of this device.Final Result: The reviewers determined that the requested interspinous and interlaminar stabilization/distraction devices (spacers), is 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 1, 2 and 3 are board certified in board certified in orthopedic surgery 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 patient has requested reimbursement for residential treatment center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the patient met the six ASAM criteria for RTC services. Accordingly, the RTC services provided were medically necessary for 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 with subspecialty certification in addiction medicine 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 reimbursement for the Prometheus Anser ADA test. The Prometheus Anser ADA test is a quantitative measurement of serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Accordingly, the Prometheus Anser ADA testing 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 Prometheus Anser ADA testing 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 Prometheus Anser ADA testing was 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 internal medicine with sub-specialty certification in gastroenterology 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 enrollee is requesting authorization and coverage for Monovisc injection to the right knee. The enrollee has osteoarthritis of the right knee. He has a history of anterior cruciate ligament repair. The enrollee received two corticosteroid injections in the past and reported the first one helped, but the second one did not. The plan was for a magnetic resonance imaging scan of the right knee, physical therapy for two to three months, and a referral to sports medicine for Monovisc. The enrollee is requesting Monovisc injection to his right knee. The enrollee reports he has exhausted all other treatment except for surgery, and physical therapy has achieved very limited results. Research showed intra-articular hyaluronic acid (Monovisc) provides a moderate symptomatic benefit to knee osteoarthritis enrollees, and without major safety concerns. Literature shows intra-articular hyaluronic acid (Monovisc) may offer a better benefit-to-risk ratio, compared to other pharmacologic options, as measured by improvements in outcomes and substantial delays in time to total knee replacement. A literature review by a professional society showed those subjects who received hyaluronic acid were 15 percent and 11 percent more likely to respond than were those who received intra-articular corticosteroid and intra-articular placebo.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
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:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient presents with a history of a lumpectomy for right-sided breast cancer, followed by radiation therapy. In this clinical setting, the addition of tomosynthesis was the diagnostic procedure to detect recurrence. The study by Mansour and colleagues evaluated the impact of adding digital breast tomosynthesis (DBT) to full field digital mammography (FFDM) in the detection and diagnosis of breast lesions. The study demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94%, and specificity increased from 20.7% to 74% when DBT was applied. In addition, DBT allowed unnecessary biopsy to be avoided in 37.3% of patients (Mansour, et al). Based on the support in the peer-reviewed literature, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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 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: Upheld

An enrollee has requested authorization and coverage for Botox injections at a dosage of 600 units every 12 weeks. Cervical dystonia (CD) is a movement disorder that is clinically characterized by involuntary contractions of cervical muscles which cause abnormal head movements and postures. The Highlights of Prescribing Information for Botox recommend a total dose not to exceed 360 units administered every 1216 weeks, or at longer intervals, with dosing tailored to the individual patient based on head and neck position, localization of pain, muscle hypertrophy, patient response, and adverse effects history. This recommendation is based primarily on the protocol of a pivotal, randomized, double-blind, placebo-controlled phase 3 clinical trial. In this case, the patient has cervical dystonia with torticollis and laterocollis. She has been treated with Botox injections, and her provider has requested further treatment with an increase of dose up to 600 units. However, the medical literature does not support a dosage of greater than 360 units. Accordingly, the requested Botox injections at 600 units every 12 weeks are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested dosage of medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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.