Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene expression classifier for evaluation of the enrollees indeterminate thyroid nodule. Findings:  Two of three physician reviewers found that While FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma gene expression classifier utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, Afirma gene expression classifier was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were likely to be more beneficial for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the knee. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. Studies found An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films.  Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms.  Patients with persistent or recurrent unexplained pain after 3-6 weeks of conservative treatment may require MRI and may require referral to an orthopedist as a next step in the evaluation.  However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. This patient does not have a fracture based on previous diagnostic tests. The question of  when or whether to obtain an MRI of the knee, in the clinical setting of knee pain, is important. In this particular patient, his physical examination did not support a meniscal tear or a ligamentous injury or tear. Moreover, an orthopedic intervention was not recommended.  The only reason to obtain an imaging study is if it will change the course of treatment, and according to the records, this is not the case for this patient. The medical literature indicates that obtaining MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery. For these reasons, the requested MRI of the knee is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested he breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that tomosynthesis provides advantages to radiologists in the interpretation of digital mammography. Particularly, in cases where there is extremely dense or heterogeneously dense breast tissue as found in this case. The tomographic technique commonly allows radiologists to separate dense glandular elements from underlying architectural distortion/mass which are findings suspicious for cancer. This separation results in a decrease in callbacks and increase in the detection of small cancers. Thus, the addition of tomosynthesis is considered more beneficial to the patient than screening mammography alone. 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 12 weeks of Harvoni for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. 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 stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested 12 weeks of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary 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 HCV should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the request for Zepatier 50-100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients HCV, genotype 1a 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi and Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. In this case, the patient does not have cirrhosis, and no other reason for urgent re-treatment compatible with the high-urgency group in the guidelines is provided. Even if re-treatment were necessary per the guidelines, the requested regimen would not be appropriate, as after failure of an NS5A inhibitor such as Harvoni, the Sovaldi, Zepatier and ribavirin regimen is only recommended by the guidelines when resistance to both NS5A and nonstructural protein 3 (NS3) inhibitors is present. In this case, NS5A resistance is present, but NS3 resistance testing is not provided. For these reasons, the request for Sovaldi and Zepatier is not supported as medically necessary for the re-treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. 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.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed was likely to have been superior over other methods of evaluating this patient.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: 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: 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 the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides significant advantages to radiologists, particularly in cases of dense tissue.  This has resulted in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional images was likely be of greater benefit to this patient than had the examination been done with the two-dimensional technique alone.  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  for a continuous glucose monitoring system for treatment of the enrollees type 1 diabetes mellitus. Findings:  The physician reviewer found that continuous glucose monitoring systems have proven to be useful tools in finding unexpected hypoglycemia and hyperglycemia in insulin-treated patients who are not in good control.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested for speech therapy for treatment of his autism. Findings:  The physician reviewer found that individuals with autism spectrum disorders often require treatment for social communication disorders. Due to the complex nature of language and communication, effective therapies will likely need to encompass a variety of settings and should include both therapists and peers in order to facilitate functional communication and social skills.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an  enrollee has requested authorization and coverage for radiofrequency neurolysis. Findings:  the reviewers found that the documents note a history of sciatica leg pain that improved. However, there is no documentation of facet joint pain and the cause of the patients back pain remains unclear. Further, there are no imaging studies that show only facet arthritis. Final Result: The reviewers determined that the requested procedure 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: physician reviewers are board certified in orthopedic surgery 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 Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. 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 stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection.  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. 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 genetic testing. Findings:  Two of the three physician reviewers found fetal aneuploidy screening is supported for all pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Cell-free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities, including sex chromosomes. There are several commercially available tests, including MaterniT21. Currently, the non-invasive screening test of choice for aneuploidy is cell-free DNA testing, regardless of the patients age. However, aneuploidies are more common in patients older than 35 years. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common. Sex chromosome abnormalities such as Turners syndrome include significant associated medical morbidities. There is sufficient support for the services at issue in this clinical setting. This technique has been highly validated and shown to have a high detection rate. This testing allows patients to make important clinical decisions regarding the pregnancy. Therefore, genetic testing was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 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: Upheld

A 51-year-old female enrollee has requested for gastric Lap-band surgery for treatment of her obesity. Findings:  The physician reviewer found that the current medical evidence does not support the requested gastric Lap-band procedure in this clinical setting.  For patients with a body mass index of 35 or less, bariatric surgery may be indicated if the patient has obesity-related comorbid diseases.  The submitted medical records do not demonstrate that this patient has obesity-related comorbid disease.  In addition, the patient has not completed essential aspects of a pre-surgical program prior to bariatric surgery, including medically supervised attempts at weight loss.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 30-year-old male enrollee has requested authorization and coverage for Mavyret. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. These recommendations apply regardless of fibrosis stage. For these reasons, the requested treatment with Mavyret  is supported as medically necessary for the treatment of this patients hepatitis C infection.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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested for an MRI of the right knee for evaluation of the her knee pain. Findings:  The physician reviewer found that an MRI is indicated to evaluate the possibility of meniscal tear on other significant internal abnormality.