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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested an insulin pump for the treatment of the enrollees medical condition.  Findings: The physican reviewer found that this patient has a history of widely fluctuating blood glucose levels before meals, glycemic control that is suboptimal, and variations in her daily activity schedule and eating plan such that a multiple dose injection regimen is unlikely to be adequate to maintain glycemic control and prevent severe hypoglycemia. Several studies published in peer-reviewed journals have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes.  Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain and reduces the frequency of hypoglycemic events.  All told, the requested insulin pump is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 33-year-old male who sustained a complete ACL tear in June 2003. He underwent reconstructive surgery in September 2003 and apparently went through a rehabilitation program. On or about 10/29/03, a custom right knee orthosis was requested in order to allow the patient to return to sporting activities. There is no documentation of the patient having any post-operative instability, arthritis or pain.The information provided gives no indication that the patients knee was unstable post-operatively. It appears the equipment was ordered as a prophylactic over concern regarding further injury. There is no literature demonstrating the efficacy of braces in a stable knee following ACL reconstruction. Based upon this information, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested epidural steroid injections for treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  There is a lack of documentation of physical findings consistent with lumbar radiculopathy.  The records do not document motor or sensory loss or loss of reflexes.  Additionally, there is no nerve conduction velocity/electromyography (NCV/EMG) testing documented. Clinical practice guidelines suggest documenting these before embarking on any intervention.  There is also a lack of documentation of physical therapy or medication trials prior to these interventions.  A large controlled trial by Friedly and colleagues, in which both patients and clinicians were unaware of the treatment assignments, provides no evidence of a treatment effect at six weeks with fluoroscopically guided epidural injections of glucocorticoids plus lidocaine as compared with lidocaine alone.  In sum, epidural steroid injections were not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 anesthesiology with sub-specialty certification in pain 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus genotype 1a. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C 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. Although prior use of ribavirin is unclear in this case, the guidelines recommend that non-cirrhotic 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. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the 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 reimbursement for the digital breast tomosynthesis performed.  Findings:  The physician reviewer found that the digital breast tomosynthesis performed on the date of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. A study found that the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, 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 . Given the support above, the services at issue were 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.Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. All 3 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 Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) nationally recognized treatment guidelines there are several options with similar efficacy recommended for treatment-naive patients with HCV genotype 1b infection. Per AASLD/IDSA guidelines Harvoni has identical rating and equivalent efficacy as Viekira Pak. Per AASLD/IDSA, daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection as a Class I, Level A rating. In addition, per guidelines daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir (plus twice-daily dosed dasabuvir) for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection as a Class I, Level A rating. The addition of weight-based ribavirin is recommended in patients with cirrhosis. However, this patient does not have cirrhosis, and therefore is a candidate for Viekira Pak without ribavirin. This regimen is highly recommended by AASLD/IDSA guidelines, and has been approved for the patients use in treatment of her HCV. As such, the request for Harvoni for 12 weeks is not medically necessary given the Health Plans approval of Viekira Pak for treatment of the patients HCV which has identical rating and equivalent efficacy per AASLD/IDSA guidelines.Final Result: The reviewer determined that the requested medication 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 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 individual weekly psychotherapy services for treatment of her posttraumatic stress disorder.  The physician reviewer found that trauma-focused psychotherapeutic interventions represent the gold standard treatment for individuals diagnosed with posttraumatic stress disorder.  Cognitive processing therapy and prolonged exposure in particular demonstrate enduring treatment gains and robust remission rates.  In reviewing the record, there was mention of eye movement desensitization and reprocessing, which is an evidence-based therapy.  However, there was no documentation regarding the specifics of the intervention.  Based on the documentation provided, the patient has not been treated with an evidence-based psychotherapy for the diagnosis of posttraumatic stress disorder.  Such therapies are steeped in cognitive behaviorism which may further benefit the patient as they are proven interventions for clinical depression as well.  The relevant peer-reviewed literature and current practice guidelines indicate that a 12-week course of trauma-focused behavioral treatment for posttraumatic stress disorder provided by a subject matter expert is sufficient to sustain improvement for up to five years.  In sum, the medical necessity of individual weekly psychotherapy services with an indefinite end date has not been established.  However, an initial course of 12 weekly individual psychotherapy sessions is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in 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

A 53-year-old male enrollee has requested Cyberknife (stereotactic radiosurgery) for the treatment of his metastatic lung cancer. Findings:  Two physician reviewers found that there is a paucity of available clinical studies on the use of Cyberknife, and those available have primarily involved patients with single or perhaps a few pulmonary metastases whereas this patient has a multitude of metastases. Hof and colleagues indicated that the potential benefits of Cyberknife were demonstrable, but their study included 61 patients with a total of 71 metastases, thereby suggesting that each patient had one or perhaps two metastases in the study. While overall survival and local tumor control rates were measured at 12, 24, and 36 months after therapy with promising results, the use of Cyberknife is still investigational or experimental in the patient subset with many metastases and not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that Botox injections are considered experimental for the treatment of the enrollees multifactorial cervical and lumbar spine disease.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene expression profiling test for evaluation of her medical condition.   Findings:  Two physician reviewers found that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is convincing scientific evidence that genetic testing of the uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis. The test at issue is standard of care and most providers who treat patients with uveal melanoma routinely utilize this test for their patients. Moreover, this test determines how closely the patient is monitored and screened for metastasis. The testing information allows the reduction of frequency screening for those that are in the low risk category. Therefore, it is important to obtain the genetic information about the tumor when the opportunity is available, as it may not be possible to obtain later.  In the case of uveal melanoma there may only be one chance to obtain this genetic information from the tumor and it is typically in the beginning or until much later if there is metastasis. Thus, the testing at issue provides critical prognostic information that would not be available otherwise. As such, the services at issue were 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: One reviewer is board certified in ophthalmology and is actively practicing. Two reviewers are board certified in medical oncology 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 one-year-old male enrollee has requested in home physical therapy for treatment of the enrollees hypotonia and generalized weakness.  Findings:  The physician reviewer found that this patient has developmental motor delay due to his hypotonic muscular development. The hypotonia is most marked in the largest muscles groups which support the body including the legs and the paraspinal muscles. His disorder is likely congenital and may improve with time. This condition is known as congenital benign hypotonia. Carboni and colleagues reports on a fairly good outcome in these children, but states that muscle stretching by physical therapists is essential for these children to evolve improved motor function. Parush and colleagues have a less favorable outlook for these children and suggest that hypotonia will continue to plague their large motor groups throughout childhood when compared with their peers. The authors also recommend continuous physical therapy and occupational therapy. Other forms of congenital hypotonia are due to primary myopathies which have a variable prognosis depending on the form of myopathy. Even in an example of a relatively severe myopathy, physical therapy is recommended even though the patient is extremely hypotonic (Malicdan and Nishino). All told, physical therapy, weekly for a 12 week course, is medically necessary for this patient. However, there is no indication for the physical therapy to be conducted within the home as requested. Therefore, the patient should receive once weekly physical therapy for 12 weeks at the providers facility.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested Dilantin (400mg/day) for treatment of her epilepsy.  Findings:  The physician reviewer found that the patient has a history of epilepsy and benefited from Dilantin with no generalized seizures for 3 years. The patient is intolerant to Keppra and had breakthrough seizures on Trileptal resulting in an emergency room (ER) visit. According to Yamada and Welty, there should not be a problem with generic substitution, although some patients are more prone to problems with the generic products. Some evidence suggests that switches between multiple generic antiepileptic drugs (AEDs) products in certain individuals may be problematic. Furthermore, the American Academy of Neurology (AAN) states, The AAN opposes policies that would result in arbitrary switching among anticonvulsants. Therefore, the AAN opposes generic substitution of anticonvulsants for patients with epilepsy at the point of sale (e.g., in the pharmacy), without prior consent of the physician and the patient. Unlike other diseases, a single breakthrough seizure due to change in delivered medication dose can have devastating consequences, including loss of driver's license, injury, and even death. In this patients case, consequences of breakthrough seizures can be substantial and she has done well previously with Dilantin and has tried and failed Keppra and Trileptal. Based on the medical records provided for review and the peer-reviewed literature cited above, the medical necessity of Dilantin (400mg/day) has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexcom continuous glucose monitoring system (CGMS). As noted in the medical literature, CGMS is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. CGMS can help identify fluctuations, maintain glycemic control, and prevent hyperglycemia and hypoglycemia. In addition, CGMS can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. Moreover, CGMS has been shown to improve hemoglobin A1C levels in diabetic patients. With the requested CGMS, this patient will be able to improve his glycemic control and thereby decrease the likelihood of developing diabetic complications. Consistent with these findings, a Dexcom CGMS is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A 53-year-old male enrollee has requested Rituxan therapy for the treatment of his multiple sclerosis. Findings:  Two physician reviewers found that at this time there is no data indicating that a particular drug is likely to have long-term effectiveness in the treatment of SPMS. While Rituxan is not a conventional treatment in this setting, there have been published studies of its use in RRMS. (Hauser, et al). Rituxan appears to have produced dramatically beneficial results in some patients. Given the limited knowledge available regarding the treatment of SPMS, Rituxan is a medically  appropriate and reasonable treatment option.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injections. The current evidence suggests that viscosupplementation for treatment of ankle osteoarthritis is a safe and effective treatment modality. Injections of hyaluronic acid into the ankle can be used to provide pain relief and to delay the need for major surgery in patients with osteoarthritis of the ankle. One study evaluated 50 consecutive patients undergoing a three-injection protocol of sodium hyaluronate viscosupplementation in the ankle. The study compared the patients pre- and post-treatment opinions about their ankle problems and found that intra-articular injection of sodium hyaluronate viscosupplementation is a beneficial conservative therapy for osteoarthritis of the ankle. In light of the foregoing, the requested Synvisc injections are medically necessary for treatment of this patients severe osteoarthritis of the right ankle.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.