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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for Forteo. Teriparatide (Forteo) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Teriparatide reduces the risk of vertebral fractures by about 65% and non-vertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy. These results are superior to other osteoporotic agents available. In this case, teriparatide (Forteo) is medically necessary for this patient, who has experienced severe bone loss. The patient is at high risk for fracture, loss of height, chronic pain and possible nerve compression damage should she develop compression fractures in the spine. It is best standard of care to prevent fractures and comorbidities by providing her the best therapy available. Furthermore, choosing a bisphosphonate or denosumab prior to teriparatide would hinder the optimal effect that can be obtained with teriparatide as first-line of therapy in this case. 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 endocrinology 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: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the scientific data suggests 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 speech and occupational therapies, can be used to help induce brain plasticity. The ultimate goal is to retrain neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their co-morbidities including, but not limited to speech delay. Key to this patients case is that a laryngeal or oropharyngeal anatomical anomaly is not essential for abnormal language motor development that is seen in young patients with autistic spectrum disorder. Thus, the medical necessity of speech therapy and occupational therapy services for management of this patients deficits related to autistic spectrum disorder is consistent with the recommendations in the medical publications and should be considered the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation 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 cutaneous melanoma. Findings:  The physician reviewer found that the DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and has the ability stratify whether a thin melanoma is high risk for metastasis. This test has shown some accuracy determining risk of metastasis in thin melanomas. However, the results of the test are indeterminate at this time. The treatment of this patient would not change based on the results of the testing. The testing at issue is not considered the standard of care. There is a lack of medical literature to support its use in the care of patients with thin melanomas to effect health outcomes. Given the lack of published data supporting its use, DecisionDx-Melanoma 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 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: Reviewers 1, 2 and 3 are board certified in dermatology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. 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 solved. 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. Considering the extra radiation dose, tomosynthesis has not been shown to provide significant increased value in patients who have normal breasts without dense tissue that could obscure an abnormality, especially when old mammograms are available for comparison, and there has been no interval change.  Final Result:  Two 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. 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 57-year-old female enrollee has requested Lyrica for treatment of her peripheral neuropathy.  Findings:  The physician reviewer found that this patient has chronic neuropathic pain. Lyrica is often useful for the treatment of neuropathic pain from a variety of sources. The Health Plan denied the request for Lyrica noting that there is only FDA approval of the use of Lyrica for post-herpetic neuralgia (PHN), diabetic neuropathy pain, fibromyalgia, and epilepsy. PHN and diabetic neuropathy are often the most-studied conditions in new medication trials for neuropathic pain due to their relatively high prevalence. Medications useful for the treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes. The clinical literature supports the benefit of Lyrica not only for diabetic peripheral neuropathic pain, but also for other painful neuropathies. Treatment in this case can reasonably be extrapolated from the clinical data and experience with the use of Lyrica for the treatment of diabetic neuropathy, as well as this patients prior beneficial experience with Lyrica. Based on such data, the use of Lyrica in this particular setting is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vosevi for 12 weeks for treatment of the enrollees hepatitis C. 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. The guidelines recommend that cirrhotic or non-cirrhotic genotype 1a patients who have failed a nonstructural protein 5A (NS5A) inhibitor should be treated with regimens including Vosevi for 12 weeks. These guideline recommendations are based on the clinical trial results showing a 96% cure rate in genotype 1a patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 24 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  The guidelines state that patients with cirrhosis are high priority for treatment, and patients with diabetes are at risk for fast progression of fibrosis.  Per the guidelines, ribavirin-ineligible patients with decompensated cirrhosis, regardless of prior treatment, should be treated with Harvoni monotherapy for 24 weeks.  There is data to support this regimen, and the guidelines also cite a study demonstrating that 12 weeks of Harvoni monotherapy is inadequate.  For these reasons, the requested treatment with Harvoni for 24 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 sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that Sovaldi has been approved by the U.S. Food and Drug Administration for patients with chronic hepatitis C genotype 2. Pursuant to 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. The guideline recommendation for treatment-naive genotype 2 patients is Sovaldi and ribavirin for 12 weeks. Multiple randomized clinical trials support the use of Sovaldi in this setting (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. As such, the requested Sovaldi 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 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 42-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees Graves disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 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 non-liver-related conditions. This applies regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed peg-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 94% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 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 sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  for speech therapy for treatment of the enrollees expressive and receptive language delays. Findings:  The physician reviewer found that Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech therapy for children with primary expressive language disorder.  This patient demonstrates significant expressive language delay, and this is negatively impacting her ability to communicate in a functional and age-appropriate manner.  The current medical literature indicates that speech therapy can result in significant improvement in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for an annual breast screening examination. Findings:  The 3 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 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.  It was stated that this patient has dense breasts as well as scattered benign nodules.  It is specifically those patients who have dense breasts that can benefit most from digital tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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: Physician reviewer number one is board certified in diagnostic 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.Physician reviewer number two is board certified in diagnostic 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.Physician reviewer number three is board certified in diagnostic 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: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested Applied Behavioral Analysis (ABA) therapy at a frequency of 12 hours per week and ABA supervision at a frequency of 4 hours per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Additionally, the peer-reviewed medical literature has demonstrated that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disabilities (Grey and Hastings). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The goals for older children are often to identify and remediate particular deficits, including non-compliance, aggression, and preoccupations and ritualistic behaviors, such is the case with this patient; and to improve his overall adaptive, socialization and communication skills. Therefore, the requested 12 hours of one to one ABA therapy per week and 4 hours per month of ABA supervision are medically necessary for treatment of the patients autism.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, speculation, and architectural distortion. Final Result: Two of 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. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for group speech therapy for an hour, once a week and after school hours. Researchers  recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. The authors noted that further development of therapy plans and interventions targeting pragmatics is lacking. At present, per the description by the patients speech provider of his behavior, the requested group speech therapy is not medically necessary. While he should benefit from continued individual speech therapy, his behavior is not conducive to him benefitting from group speech therapy. His behavior is also likely to be disruptive to other children in the group speech therapy session. The provider reports that the patient has limited joint attention and his inability to be present prevent him from participating and being successful in a social learning group. The patient has also demonstrating grabbing behaviors that are interfering with the therapy process. With continued applied behavioral analysis (ABA) therapy and individual speech therapy, the patients behavior and verbal ability may improve to the extent that he may benefit from group speech therapy in the future. For these reasons, the requested group speech therapy for an hour, once a week and after school hours, is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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 neurology with special qualification in child 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.