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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees chronic hepatitis C virus (HCV) 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. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Epclusa for 12 weeks, 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 (Feld, et al).  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 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 authorization and coverage for letermovir (Prevymis). As noted in the medical literature, cytomegalovirus (CMV) keratouveitis is well recognized clinical entity which is often present along with high eye pressure. In this case, PCR results and the patients response to valganciclovir confirm this diagnosis. However, since the patient has developed side effects due to valganciclovir, it is no longer a viable treatment option. Prevymis is a new medication for the management of systemic CMV infection. Based on the scientific data demonstrating its efficacy against CMV, Prevymis is supported as medically necessary for treatment of this patients medical condition. 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 ophthalmology 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 35-year-old female enrollee has requested for a breast MRI  study for a history of breast cancer.   Findings:  Three physician reviewers found that the use of breast MRI has been shown to be efficacious in certain patient populations for both screening and diagnostic purposes. The breast MRI can better evaluate the remaining left breast tissue and area of scarring for malignancy than mammography.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old male has requested social skills group therapy for treatment of his autism. Findings:  The physician reviewer found that Meyers and colleagues state that families of autistic children can facilitate joint attention and other reciprocal social interaction experiences throughout the day in the childs regular activities. Further, a controlled study comparing target treatment of 51 socially dysfunctional children who were divided into two treatment arms, community based and individual treatment, found that the community based group social treatment was much less effective in improving social behavior than individualized targeted treatment, similar to what this patient has been receiving via his sessions with the Plans Child Psychiatry Department (Casenhiser, et al.). Given the available peer-reviewed medical literature, the requested social skills group therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 21-year-old female who was reportedly doing well in college prior to her admission to residential treatment. She had a history of once daily bulimic episodes since adolescence and also reported the use of enemas. It appears she had maintained her weight within normal parameters for her height. The patient participated in the program with individual therapy on average three times per week. Her request for reimbursement for the residential treatment services provided from December 2005 through January 2006 was denied by the Health Plan citing a lack of medical necessity.The medical records provided were reviewed in their entirety. The patient had no identified co-morbid medical or psychiatric diagnoses and her weight was within the normal range for her height. There is no record of participation in an intensive outpatient treatment program before her elective admission to the specialized residential treatment program for eating disorders.  There is no indication of failed treatment at the outpatient level, in fact her provider noted that outpatient treatment attempts have been partially effective. According to the American Psychiatric Association guidelines for the treatment of bulimia nervosa the patient did not require treatment at the residential level of care. Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for enzalutamide (Xtandi) 40 mg quantity of 360 for the duration of 90 days. Findings:  The physician reviewer found that  Xtandi is a potent androgen receptor inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of castration-resistant prostate cancer and metastatic castration-sensitive prostate cancer. Traina and colleagues evaluated Xtandi for treatment of patients with metastatic triple-negative breast cancer. The authors evaluated 118 patients with androgen receptor-positive metastatic triple negative breast cancer. The authors found that their study supports additional development of Xtandi for patients with advanced triple negative breast cancer. This patient does not reportedly have metastatic disease and she has received neoadjuvant and adjuvant therapy for her triple negative breast cancer. Therefore, the requested enzalutamide (Xtandi) 40 mg quantity of 360 for the duration of 90 days is not medically necessary for treatment of this patient.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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-month-old female enrollee has requested for Synagis injections for treatment of the enrollees RSV risk. Findings:  The physician reviewer found that the American Academy of Pediatrics guidelines published in 2003 recommend palivizumab for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of RSV season if they possess two additional risk factors. These risk factors include school age siblings, day care attendance, airway abnormality, neuromuscular disease, and/or exposure to environmental air pollutants. There are, however, additional risk factors that not only increase the chance of morbidity, but also mortality, from RSV disease in infants up to 12 months of age. The most striking of these is a birth weight less than 2500 grams. An infant with a birth weight between 1500 and 2500 grams is 5 times more likely to die from RSV infection than an infant with a birth weight greater than or equal to 2500 grams, as noted by Holman and colleagues.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested Avastin chemotherapy treatment in combination with vinorelbine (Navelbine) for the treatment of her breast carcinoma. Findings:  The physician reviewer found that Avastin has been approved for use in metastatic breast cancer, as first line therapy of metastatic disease, along with Taxol. There is no real data for its use in breast cancer in other situations and/or combinations. Its use here would be a situation in which there is no proven clinical benefit, and it is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. Differential diagnosis is critical to designing appropriate intervention, which should be tailored to the parents goals along with the patients clinical and educational needs. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. Shevell and colleagues evaluated patients under 5 years of age who were referred over an 18-month period to subspecialty services for initial evaluation of a suspected developmental delay. Of these patients, 99 children (71 boys) were found to have global developmental delay with 96% found to have a mild or moderate delay. It was concluded that an etiologic diagnosis is often possible in the young patient with global developmental delay, particularly in the absence of autistic features. Overall, research shows that children with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. In addition, patients seen alone for treatment tend to progress better than those seen in groups. As the patient improves, treatment may be indicated less frequently, and group therapy may become a more appropriate alternative. DeThorne, in his article, found experimental support for 6 treatment strategies that have been used to facilitate speech development in young children with developmental disabilities, thereby showing that therapy does help. In this case, the report by the speech therapist is below standards as it fails to provide a diagnosis or degree of delay, goals, prognosis, or physical or anatominal examination. The patient in this case does not have any evidence of autism, however the provider apparently did not examine him further for an etiology of his speech delay. Thus, a detailed and complete speech and language evaluation should be performed by an independent therapist for an accurate diagnosis. A work-up should also be performed to look for possible etiology of the patients speech delay. Given this patients speech and language delay, it is medically necessary for this patient to receive the requested speech therapy services for a minimum of five hours per week.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus. Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. AASLD/IDSA further state, The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, the patient should be approved for treatment of HCV. Thus, Harvoni is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has requested reimbursement for thawing cryopreserved embryo and assisted embryo hatching MicroTQ services. The American College of Obstetricians and Gynecologists (ACOG) reports that oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. However, the ACOG states that there are not yet sufficient data to recommend oocyte cryopreservation for the sole purpose of circumventing reproductive aging in healthy women. The medical records for this patient indicate that cryopreservation of fertilized embryos was performed with the intention to prolong fertility until later in life. The records provided for review do not document a medical indication for oocyte cryopreservation due to chemotherapy or other gonadotoxic therapies. For these reasons, the thawing cryopreserved embryo and assisted embryo hatching MicroTQ were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure testing for evaluation of the enrollees possible rupture of membranes. Findings:  The 3 physician reviewers found that the AmniSure Test is utilized to aid in the detection of rupture of membranes when a patient reports signs, symptoms or complaints suggestive of rupture of membranes or premature rupture of membranes. It is a rapid, non-instrumented, qualitative immunochromatographic test for detection of amniotic fluid in the vaginal secretions of pregnant women. According to American College of Obstetricians and Gynecologists (ACOG), the diagnosis of rupture of membranes is typically confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of the vaginal fluid or ferning of dried vaginal fluid. According to ACOG, AmniSure testing is considered ancillary to standard methods of diagnosis. Therefore, the AmniSure testing performed has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology 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 obstetrics and gynecology 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 obstetrics and gynecology 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 a Squeeze Machine.Medical literatures state, Non-psychopharmacological studies were mainly randomized controlled trials (RCTs) with cognitive behavior therapy demonstrating moderate efficacy for anxiety disorders in youth with high functioning autism spectrum disorder (ASD). Although there are other treatments that are non-psychopharmacologic for treatment of anxiety in patients with ASD, these interventions require higher cognitive capabilities than this patient has. Researchers indicate that the risks of treatment with deep pressure are very limited, but the potential for harm without the deep pressure is quite high. The authors also state, Deep pressure appears to be of immediate benefit to this population with autism and severe intellectual difficulties. In this case, the patient has been diagnosed with autism. Additionally, there is a history of injuries due to the patients condition. However, other non-psychopharmacological interventions, like cognitive behavior therapy, would not be effective for this patient because she is not high functioning. The requested equipment would help in calming down anxieties and replace self-injurious behaviors. Therefore, the requested Squeeze Machine is medically necessary for treatment of this patients medical condition.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for facial feminization surgery. The World Professional Association for Transgender Health (WPATH) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Medical literature notes that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria. The patients providers support the presence of masculine facial features, which contribute to the patients gender dysphoria. Given these findings, the requested facial feminization is medically necessary for treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Spinraza. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees spinal muscular atrophy type III.Findings:  The request for Spinraza is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Recent clinical studies have shown Spinraza to be an effective treatment for SMA.  Per the medical literature, it is the only drug with U.S. Food and Drug Administration (FDA) approval for treatment of SMA. SMA is an autosomal recessive degenerative neuromuscular disorder characterized by loss of spinal motor neurons leading to muscle weakness. In a published study of Spinraza for the treatment of SMA researchers stated that the studies show improvement in motor function across SMA of all types, including SMA type 3.  Best motor response was observed with early treatment and pre-symptomatic treatment prevented disease manifestations. Maharashi and colleagues note major evidence of Spinraza efficacy came from a sham controlled phase 3 clinical study ENDEAR. According to the literature, all the patients were transitioned to receive Spinraza in an ongoing open label, phase 3 study, SHINE. Therefore, Spinraza is likely to be more efficacious than the available modalities for the treatment of this patients SMA, type III.Final Result: Two of the three reviewers determined that requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in neurology 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.