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 Mavyret for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. Further, the AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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 male enrollee requested authorization and coverage of out-of-plan high dose brachytherapy for the treatment of prostate cancer.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old male who has a history of gastrointestinal bleed due to NSAID medication. He has rheumatoid arthritis and bilateral carpel tunnel syndrome and has been tried on Celebrex with good results. He wishes to continue on Celebrex and has requested authorization and coverage for the medication from the Health Plan. The Health Plan has denied his request indicating the patient has not tried and failed an NSAID and a proton pump inhibitor combination. At issue is whether Celebrex is medically necessary for the patient.Review of the submitted clinical information indicates Celebrex has been beneficial for the patient. There is no reason to have the patient try and fail another NSAID and risk sustaining another GI bleed. Celebrex has been shown to be effective in his case and its continued use by the patient is medically appropriate and clinically indicated given his history of GI bleed. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
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: Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  The technique often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks, decrease in biopsies and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis was likely of greater benefit to the patient than had her study been done with two-dimensional technique alone.  In sum, breast tomosynthesis was likely to have been of greater benefit than 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 patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: All three physician reviewers are 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 authorization and coverage for a high frequency chest wall oscillation air-pulse generator system. Findings: Two of the three physician reviewers found that the requested high frequency chest wall oscillation air-pulse generator system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient has very slow and low expiratory volume (likely due to his COPD) for devices such as flutter valve to make a difference, and chest percussion and postural drainage needs a helper, needs to be done frequently during the day, and is poorly tolerated by many. The patient has multiple medical problems and is a very poor candidate for postural drainage. It is also reported that he has no caregiver to provide that therapy. The patient has clearly retained mucous as demonstrated in repeated bronchoscopies. HFCWO devices have the great advantage that they do not require the active participation of the patient to clear airways as opposed to positive expiratory pressure devices, nor do they require a trained adult at home. Due to the patients age, medical conditions, and a home situation that does not have a caregiver who can assist with chest percussion and postural drainage, the use of a high frequency chest wall oscillation device is 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 requested device is likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in pulmonary disease, and all three 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 Sovaldi for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the position of American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend that all patients with chronic hepatitis be treated except those with limited life expectancy of 12 months or less due to a non-liver related condition. In the past, treatment for patients with early stage hepatitis C virus (HCV) was delayed in order to wait for more effective, less toxic treatment. This has now changed as sofosbuvir (Sovaldi) plus ribavirin achieves 98% cure rate in patients with genotype 2 and has no serious adverse effects or contraindications. The U.S. Food and Drug Administration (FDA) label is clear on its approved uses which includes early stage disease. Moreover, the position of the AASLD on HCV does not stratify patients based on early or late stage disease. Therefore, per the guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. For these reasons, the requested treatment with 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400 mg  100 mg for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, treatment-naive genotype 3 patients should be treated with Sovaldi and Daklinza for 12 weeks, or Epclusa for 12 weeks. This is based on the ALLY-3 trial for Sovaldi and Daklinza, and the ASTRAL-3 trial for Epclusa (Nelson, et al; Foster, et al). There is no controlled direct comparison trial showing that Epclusa is more effective than Sovaldi with Daklinza. In addition, non-cirrhotic treatment-naive genotype 3 patients had a 97% cure rate with Sovaldi and Daklinza in the ALLY-3 trial, similar to the 98% cure rate with Epclusa in ASTRAL-3.  There is a lack of medical records showing a contraindication to treatment with Sovaldi and Daklinza. Although hepatitis C treatment is needed, Epclusa has not been established as medically necessary in this clinical setting.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 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

An enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services. The submitted documentation supports that Intensive Outpatient Program (IOP) services were medically necessary. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. The patients composite score indicates that the patient would have qualified for a Level 4: Medically Monitored Non-Residential Services level of care during the period under consideration. This more intensive level of care rating supports that Intensive Outpatient Program (IOP) services were medically necessary. Accordingly, Intensive Outpatient Program (IOP) services were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the 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 42-year-old female enrollee has requested for speech therapy for treatment of her dysphonia. Findings:  The physician reviewer found that the requested therapy sessions may be beneficial and are medically indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the medical literature supports the use of ABA therapy in the treatment of children with autism. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in autistic children. The above-referenced paper by Spreckley and Boyd is a meta-analysis review of the available literature regarding the effectiveness of ABA therapy. The authors concluded that ABA therapy is an effective modality, however, not all children will benefit. As this patient has received ABA therapy without significant response, the continuation of ABA therapy for behavioral modification is not likely to be effective. However, continuation of ABA treatment in an attempt to modify one or two behaviors can be effective for the older child (Reichow, et al). The patients pediatrician suggests that the one of the goals of the ABA therapy should be directed to proper stool self-cleansing. As such, it is medically reasonable and necessary for the patient to continue ABA therapy and supervision.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested  for mental health residential treatment for treatment of the enrollees bipolar disorder, developmental disorder, and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is useful in determining the necessary level of care for children, to ensure their level of care meets their individual needs at the least restrictive setting possible. Based upon these guidelines, the patient met criteria for residential treatment at admission. However, his progress in treatment indicates he was using coping skills and his behavior had improved through the course of treatment overall.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee requested authorization and coverage of Botox injections for her chronic migraine headaches. The Health Plan denied the request indicating that the requested procedure is considered investigational/experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested for the medication Rituxan for treatment of his  multiple sclerosis.   Findings:  Two physician reviewers found that although clinical trial data examining the role of Rituxan in multiple sclerosis is limited, there is scientific rationale for the use of Rituxan in this setting. In this particular case, given that the patient has failed previous therapy, and his symptoms have progressed, Rituxan is medically appropriate and warranted for treatment of his patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested continued residential treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the services at issue. In this case, the patient has failed less restrictive therapeutic settings and residential programming was recommended by her treating providers who best knew the patient and the family system. This represents a critical factor in the placement determination process.  The patients family and social environment, coupled with her agitation and mood symptoms, were not conducive to a less restrictive setting and a one-week stay at a residential level of care was not long enough to make meaningful treatment gains. From a psychodynamic perspective, the patient was clearly underdeveloped in terms of self-acceptance and executive functionality with stunted abilities to self-soothe and delay gratification. The patient was on a path of role diffusion, rather than sound identity formation, which would have surely fueled continued behavioral dysregulation, intrapsychic conflict, and societal misconduct with resultant behaviors that would have posed risk of serious harm to the patient and possibly others. Thus, continuation of residential treatment beyond the date indicated is the most appropriate disposition and the one that offers the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains. Considering the clinical presentation, patient history, and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment at the residential level of care was and is safe, appropriate and medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested a sleep study for an evaluation of her insomnia. Findings:  The physician reviewer found that the patient presents with specific symptoms characteristic of sleep apnea as described in all relevant sleep literature and in the Health Plans guideline itself. The description of symptoms is very specific and includes: snoring, gasping, morning headaches, and fatigue. Failure to appropriately diagnose and subsequently treat this patient is likely to lead to increased morbidity. Practice parameters dictate that a sleep study is appropriate and necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio. This patient presents with a history of ulcerative colitis. Currently, the provider noted that the patient is experiencing a flare of his condition. The patient has been treated with prednisone. Prior treatment has also included Asacol. The patients provider has recommended treatment with Entyvio. As noted in the medical literature, Entyvio has been demonstrated to be safe and effective for the treatment of patients with ulcerative colitis (Rubin, et al.). In addition, one study found evidence of superior response to Entyvio when compared to tumor necrosis factor agents such as infliximab in patients with ulcerative colitis (Sands, et al.). The American Gastroenterological Association (AGA) guidelines state that, Patients, particularly those with less severe disease, who place higher value on the potential safety of medications, and a lower value on the relative efficacy of medications, may reasonably choose vedolizumab (Sands, et al.). Additional data have reported on the efficacy of Entyvio for the treatment of patients with ulcerative colitis in high-quality studies, including randomized controlled trials (Mosli, et al.; Lin, et al.). Given this support, the requested Entyvio is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for Genetic cancer screening performed by Myriad Genetic Laboratories.  The myRisk test includes a panel of genes important for determining the etiology of breast and ovarian cancers. The myRisk gene panel is a standard evaluation tool used to analyze genetic causes of breast and ovarian cancer. These cancers have multifactorial causes encoded by several genes, and represents an example of a polygenic etiology. Even if the patient does not meet the criteria for each individual gene, the power of all genes combined is more informative than each gene alone. The genetic cancer performed by Myriad Genetic Laboratories was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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: Upheld

A 25-year-old female enrollee has requested partial hospitalization program services for treatment of her anorexia nervosa, generalized anxiety disorder and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based upon the medical records, the patient is medically stable.  She did not show suicidal ideation, and she was not a threat towards others.  While she did have a reported incident of self-harm, it did not require medical attention.  Her weight on the date indicated was near her goal weight.  The patient has demonstrated adequate self-control in terms of over-exercising.  In terms of environmental stress, although the patient lives alone, her parents have been supportive.  In sum, the patient does not meet American Psychiatric Association guidelines for partial hospitalization program level of care.  All told, partial hospitalization program services provided from the specified date forward were not and are not medically necessary for the treatment of this patient.