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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni for 12 weeks is supported as medically necessary for treatment of this patients chronic hepatitis C virus. Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested for out-of-network services for treatment of her soft-tissue sarcoma. Findings:  The physician reviewer found that it was found that imatinib has activity for gastrointestinal stromal tumors (GIST), dermatofibroma protuberans and desmoids tumors (Demetri, et al. and MacArthur, et al.). Other tyrosine kinase inhibitors may have activity against soft tissue sarcomas such as sorafenib (DAdamo, et al.).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Foundation One genetic testing for evaluation of her medical condition. Findings:  Two physician reviewers found that next generation sequencing, such as Foundation One, is considered a standard of care in this clinical setting.  The testing performed may assist providers in making therapy decisions, and many institutions require testing before consultation to determine available clinical trials.  All told, Foundation One genetic testing was likely to have been superior over other methods of evaluating this patient. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification 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 patient is a 48-year-old woman with Crohns disease. She has not responded to conventional medical therapy. These have included 6-MP, 5-ASA, thalidomide, and steroids. The patient was recently placed on methotrexate. She developed a lupus-like reaction to Remicade. The patient continues to be symptomatic. The patient has requested authorization and coverage for Humira. The Health Plan has denied the patients request on the basis that Humira is not medically necessary for treatment of the patients medical condition.Humira is anti-TNF alpha derived from human antibody. It has been approved by the Food and Drug Administration (FDA) for treatment of rheumatoid arthritis. Humira, like Remicade, can cause lupus-like reactions. There are ongoing studies involving use of Humira in treatment of patients with Crohns disease. Although Humira has not been FDA approved for treatment of the patients condition, its use by this patient is medically reasonable. The patient has exhausted all treatments options short of surgery. In this particular patient at this stage of her disease it is medically appropriate to proceed with the requested medication. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a 20 to 30-year history of insomnia and excessive daytime somnolence. Based on a sleep study performed in April 2006, she also has mild obstructive sleep apnea. Her insomnia is managed with sedatives/hypnotics, such as Ambien. She reports that Provigil has been beneficial in reducing her daytime somnolence. She has not undergone a trial of CPAP to date. At issue is whether Provigil is medically necessary for treatment of the patients condition.Provigil has been the subject of peer-review and is considered an acceptable treatment modality for hypersomnolence. In the case of this patient, a polysomnography showed mild obstructive sleep apnea. The consensus of the treating physician is the obstructive sleep apnea is probably not significant in the patients hypersomnia. However, the patient also has insomnia. The medication prescribed for the patients insomnia is likely a contributing cause of her hypersomnolence. As such, Provigil is not clinically indicated or warranted for this patient. It is likely that behavioral modification will be more effective in this particular clinical setting. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for psychiatric intensive outpatient program services. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines indicate that admission to an intensive day program, may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. In this patients case, the records document posttraumatic stress disorder and generalized anxiety disorder complicating her condition. She has not responded adequately to lower levels of care. Given the severity of the patients illness, including prior suicide attempt and resistance to multiple prior treatments, the services at issue were and are medically necessary. Therefore, psychiatric intensive outpatient program services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested Pegasys and ribavirin for the treatment of her hepatitis C. Findings:  The physician reviewer found that there is no consensus regarding the role of liver biopsy in the evaluation of patients with chronic hepatitis. Traditionally, liver biopsy has played a central role in the management of chronic hepatitis C, reflecting the pivotal place the liver holds as the most significant organ affected by this infection. Liver biopsy findings and staging can provide a firm basis from which to make a decision as to whether treatment is warranted immediately or if watchful waiting is an option. In patients with genotype-1, most clinicians would consider doing a liver biopsy to stage the disease, as often the severity of liver disease seen on biopsy is the key determinant for treatment options.  However, as set forth above, a liver biopsy is not essential and all patients with HCV infection should be considered eligible for combination therapy with pegylated interferon and ribavirin.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that Harvoni is approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in adults. The fixed dose combination ledipasvir-sofosbuvir (90 mg/400 mg) is FDA-approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. In this case, the medical necessity for Harvoni has not been established due to the lack of information of the patients HCV viral load, genotype and fibrosis score. Harvoni is approved for genotype 1 patients only and duration of HCV therapy is determined on HCV viral load. Given the lack of documentation demonstrating the patients HCV viral load, genotype, and fibrosis score the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested for Zofran 8mg for treatment of her hyperemesis gravidarum. Findings:  The physician reviewer found that hyperemesis gravidarum often involves more severe symptoms, including weight loss, dehydration, vitamin deficiencies and nutritional deficiencies. Vomiting may result in electrolyte and acid-base disturbances and starvation ketosis. This progresses to hyperemesis gravidarum when there is dehydration, weight loss and ketonuria. Ptyalism is a frequent accompaniment, due to an inability to swallow saliva. Biochemical changes often include elevated liver transaminases, elevated free T4 and depressed thyroid stimulating hormones. Hyperthyroxinaemia associated with hyperemesis gravidarum coincides with the rise and fall of serum human chorionic gonadotropin, which has thyroid stimulating activity. Treatment of hyperemesis corrects the abnormal biochemistry.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for IOP services that were provided for a month. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether IOP services that were provided for one month were medically necessary for treatment of the patients medical condition. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by providers to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The composite CALOCUS score for this patient is 15, which indicates outpatient services level of care was appropriate for this patient. Therefore, the IOP services provided for one month were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 psychiatry with a subspecialty certificate in child and adolescent 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: Overturned

A 57-year-old female has requested Rituxan for treatment of rheumatoid arthritis.  Findings:  Two physician reviewers found that the use of Rituxan in this clinical setting is not investigational or experimental. This medication is FDA approved for use in rheumatoid arthritis that has failed methotrexate and at least one tumor necrosis inhibitor medication. She has had an initial response to the Rituxan infusion therapy, and given that the natural history of the course of this disease can be quite disabling, the patient should be allowed coverage for continued therapy with this medication.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacral nerve stimulation for treatment of the enrollees anal pain and sphincterotomy. Findings:  Two physician reviewers found that within the field of colorectal surgery, the primary indication for sacral nerve stimulation is fecal incontinence. There is a lack of significant data supporting the use of sacral nerve stimulation for levator syndrome, anal pain or chronic pelvic pain. A systematic review on nerve stimulation for chronic pelvic pain and bladder pain syndrome concluded that there were no reported data for sacral nerve stimulation. Additionally, there is a paucity of literature reporting variable success of posterior tibial nerve stimulation in improving pain, urinary symptoms and quality of life for both chronic pelvic pain and bladder pain syndrome. Finally, a small study of 60 consecutive male patients with chronic pelvic pain demonstrated that transcutaneous electrical nerve stimulation (TENS) may be an effective and safe treatment for chronic pelvic pain and that larger randomized placebo controlled trials are warranted. Given these data, the requested sacral nerve stimulation is not likely to be more beneficial for treatment of the patients anal pain than any available standard therapy. Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Two reviewers are board certified in surgery with sub-specialty certification in colorectal surgery and are actively practicing. One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned

A 60-year-old male enrollee has requested for an MRI of the bilateral hips for evaluation of his bilateral hip pain and dysplastic osteoarthritic hips. Findings:  The physician reviewer found that the MRI was indicated and warranted given the discomfort the patient was obviously experiencing. He was limping, and anti-inflammatory medications did not help. The MRI of the hips was medically necessary for further work-up of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage of allergy shots from a specialist for the treatment of allergies. 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 services are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1The patient is a 58-year-old physically active female with severe osteoarthritis of the right hip dating back to 2002. The patients symptoms and disability have become progressively worse. She has had diagnostic hip injection and a scan, which have confirmed the diagnosis. The patient has consulted a provider who has recommended hip resurfacing as opposed to total hip replacement. The Health Plan indicates hip resurfacing is considered investigational.Review of current medical literature suggests that hip resurfacing is likely to provide a favorable long-term outcome compared to standard treatment. Given the patients relatively young age and continued high level of activity, hip resurfacing is more appropriate than traditional total hip replacement. Hip resurfacing is a medically reasonable procedure and is medically indicated for the patients condition. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2The patient is a 58-year-old female with a history of degenerative joint disease of the hip. She is requesting metal-on-metal hip resurfacing. The Health Plan has denied the request on the basis that the requested procedure is considered investigational.The patient is a 58-year-old female who is in excellent health. She is a candidate for conventional total hip replacement and is likely to benefit from the procedure. There is ample long-term follow-up showing that conventional hip replacement is an appropriate procedure at the age of 58. The long-term results of hip resurfacing are not known. There is no evidence that hip resurfacing is a more appropriate procedure for patients such as this patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 58-year-old female. She is involved in a high level of activity. The description of her pain and limitations is consistent with the examination showing a limited range of motion. The patient wishes to undergo hip resurfacing. The Health Plan has denied authorization and coverage for hip resurfacing on the basis that it is considered investigational.Hip resurfacing is valid for treatment of symptomatic hip degenerative joint disease. There is greater ease of revision (should it be necessary) than with standard hip arthroplasty. Furthermore, given the increased demands of highly active patients such as this patient, there is less risk of dislocation with hip resurfacing. The patient is likely to have a better overall outcome both short- and long-term with the requested procedure. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested for intensity-modulated radiation therapy (IMRT) for treatment of his prostate cancer.  Findings:  The physician reviewer found that IMRT plus brachytherapy is a reasonable approach in the treatment of localized prostate cancer. Dosimetrically, it may be preferable to brachytherapy alone or IMRT alone. Nevertheless, IMRT is not medically necessary when combining external beam radiation with brachytherapy. There are innumerable studies to support conventional external beam radiation treatment in conjunction with brachytherapy, but there appears to be no studies that compare the dosimetry or clinical outcome with conventional radiation plus brachytherapy versus IMRT plus brachytherapy.
Appeal type: Medical Necessity
Decision: Upheld

A 73-year-old male enrollee requested authorization and coverage of follow-up care with an out-of-network retinal specialist for the treatment of retinal occlusion.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that beast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue, such as this patient.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: The reviewers determined that the service 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: the 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: Experimental/Investigational
Decision: Overturned

The parent of a female enrollee requested exome sequence analysis for medical evaluation of the enrollees ataxia and developmental delays. Findings:  Two physician reviewers found that whole exome sequencing is used as a diagnostic tool for rare genetic diseases as well as ataxia. Sawyer and colleagues noted success rate of 46% with exome sequencing when evaluating pediatric patients with ataxia. The authors note that whole genome sequencing is a powerful clinical tool that has been increasingly used to assist in the diagnosis of Mendelian disorders. For the reasons provided, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested authorization and coverage of mandibular surgery for the treatment of mandibular hyperplasia.  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 surgery is medically necessary for treatment of the patients medical condition.