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

The parents of a four-year-old female enrollee requested authorization and coverage of an ABI Vest for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees cystic fibrosis. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma assay should not be used outside of a clinical trial. In addition, the use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, the testing at issue is not expected to impact the treatment or outcome of the patients melanoma. All told, the DecisionDx-Melanoma testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in dermatology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage for the medication Vioxx. The health plan has denied this request indicating that Vioxx is not medically necessary for treatment of the enrollees low back pain.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 Sovaldi and ribavirin 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 (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. Per guidelines, treatment-naive patients with genotype 2 hepatitis C should be treated with daily Sovaldi and ribavirin 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 2 regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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

A 51-year-old female enrollee has requested an Oncotype DX tumor assay for the evaluation of breast cancer.  Findings:  The physician reviewer found that there is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. The assay has become very useful, particularly in this group of breast cancer patients for whom it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, this assay has been rapidly adopted by many oncologists as part of their standard evaluation of such patients, and Medicare has approved its use.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Mavyret 100-40 mg three tablets daily for eight weeks. 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 regardless of fibrosis stage. The guidelines recommend three Mavyret tablets daily for eight weeks for non-cirrhotic treatment-naive genotype 1a patients. These 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. For these reasons, Mavyret 100-40 mg three tablets daily for eight weeks is supported as 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 subspecialty 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 for 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.  Per the guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested treatment is likely to prevent further development and 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 enrollees medical condition.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested extracorporeal shockwave therapy for treatment of her plantar fasciitis.  Findings:  The physician reviewer found that the patient is requesting ESWT treatment without giving adequate time for healing. Generally, surgery or ESWT is performed after nine months of failed conservative treatment. Some studies show plantar fasciitis resolves in nine months in most cases. Based upon the information provided, the patient should continue with conservative therapy. If her condition is not resolved by September 2007, ESWT should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that according to the guidelines, 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. 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. In addition, guidelines cite data showing reduced survival with delayed treatment. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  Two physician reviewers found that digital breast tomosynthesis  is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. In this case, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Accordingly, the digital breast tomosynthesis performed 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 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 reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One CHDR physician reviewer concluded that the requested procedure is 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 surgery 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: Upheld

An enrollee has requested reimbursement for laboratory testing.Findings:  Three physician reviewers found that in the evaluation of rupture of membranes, available standard diagnostic evaluation can be performed with pelvic examination for pooling of amniotic fluid, testing the pH of the vaginal fluid, and microscopic visualization of the fluid for the presence of arborization. An obstetric ultrasound may be done to assess for amniotic fluid index. AmniSure is a rapid slide test that uses immunochromatography methods to detect trace amounts of placental alpha microglobulin-1 protein in vaginal fluid. Per the medical evidence, AmniSure testing may be appropriate if the diagnosis remains uncertain after physical examination, nitrazine and fern tests, and ultrasound assessment. Based on the available clinical documentation, this patients diagnosis was not uncertain. She had no evidence of rupture of membranes on physical examination or ultrasound assessment. Furthermore, it does not appear that traditional evaluation with nitrazine and fern tests were performed. Therefore, laboratory testing was not likely to have been more effective than other methods of evaluating this patient. 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: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 40-year-old female enrollee requested authorization and coverage for gastric bypass surgery for the treatment of morbid obesity.  The health plan has denied this request indicating that the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested for acute skilled nursing facility care for treatment of her medical condition. Findings:  The physician reviewer found that there is no expectation that daily skilled rehabilitation will result in further improvement. As her brain continues to heal, she will make additional progress, but this progress depends more upon brain healing than upon skilled rehabilitation. Her needs can be met at a lower level of care (such as a rehabilitative nursing program).
Appeal type: Medical Necessity
Decision: Overturned

 a 48-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients 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:  Three physician reviewers found that tomosynthesis allows the provider to separate various layers of breast tissue to better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast tissue. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  Three physician reviewers found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50/100 mg for 12 weeks.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 nonliver-related conditions regardless of fibrosis stage. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, as in this case. These guideline recommendations are based on clinical trial results. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that I have 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 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 55-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that Botox has been shown in several large, randomized, placebo-controlled studies to result in significant reduction in headache frequency and reduce the need for acute therapy. Given this patients previous response to Botox therapy, the requested therapy is likely be more beneficial for her than any available standard therapy.
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.  The primary rationale for breast tomosynthesis is the ability to separate out overlapping tissues in patients where the overall density of the breasts makes visualization of fine detail confusing.  It is specifically in those patients with dense breasts that the greatest value of tomosynthesis is found.  Thus, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  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 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 16-year-old female enrollee has requested residential treatment services for treatment of behavioral health problems.  Findings:  The physician reviewer found that she appeared engaged in treatment, but her controls were tenuously held and she clearly required continued residential treatment. The patient was not prepared for a less intensive level of care.