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

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the genetic tests (CPT codes 81200, 81242, 81260-81290, and 81330) performed on 12/15/17. The Health Plan has denied this request indicating that the services at issue were considered investigational for the evaluation of the patients pregnancy.Findings: The services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. It has been long recognized that a number of serious medical disorders are common in the Ashkenazi Jewish population. These are recessive genetic conditions. In order to reduce the incidence of these serious and lethal conditions, genetic testing has been recommended by the American College of Obstetricians and Gynecologists. This testing is readily available by commercial genetic testing facilities. Therefore, the genetic tests (CPT codes 81200, 81242, 81260-81290, and 81330) that were performed on 12/15/17 were likely to be more beneficial for treatment 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: All three reviewers 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: Experimental/Investigational
Decision: Upheld

A 27-year-old male enrollee requested authorization and coverage of liver activation treatment for the treatment of diabetic neuropathy, autonomic neuropathy, peripheral neuropathy, eye retinopathy, and kidney disease.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that liver activation treatment is not likely to be more beneficial for treatment of the enrollees diabetic neuropathy, autonomic neuropathy, peripheral neuropathy, eye retinopathy, and kidney disease than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Viekira Pak for medical treatment of his chronic hepatitis C virus genotype 1b. Findings:  Two physician reviewers 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, regardless of fibrosis, should be treated, except those with limited life expectancy due to nonliver-related comorbid conditions. In treatment-naive patients, therapy is recommended with Viekira Pak for 12 weeks. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Viekira Pak is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa. 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, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% with this regimen . The guidelines no longer recommend Sovaldi with ribavirin as first-line therapy for genotype 3 hepatitis C. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, 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: Upheld

A 55-year-old male enrollee requested immune globulin intravenous (IVIG) for medical treatment of his neuromuscular hyperexcitability syndrome (cramp fasciculation syndrome.) Findings:  The physician reviewer found that in the medical literature, Liewluck and colleagues indicate that most patients with positive antibodies can be treated with oral neuromuscular stabilizing agents such as carbamazepine, phenytoin, gabapentin, or Lyrica, and that most do not require immunosuppression. The authors also state that there is no role for use of immunosuppressant therapies in patients without evidence of autoantibodies. In this patient, no autoantibodies have been documented. Overall, there is a lack of data that identifies IVIG as a specific treatment for muscle hyperexcitability syndromes including cramp-fasciculation syndrome. For these reasons, the use of IVIG is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Actemra. The records provided for review document that this patients diagnoses include end-stage renal disease (ESRD) status post living unrelated renal transplant with persistent donor specific antibodies (DSAs). The patients DSAs have persisted despite prior therapy with rituximab and IVIG. Given this lack of response to rituximab and IVIG, it is unlikely that the patient will respond to retreatment with either of these therapies. Current data has demonstrated the potential benefits of Actemra in this clinical setting. The risk of failing therapy is poor long-term viability of the renal allograft. Therefore, the requested Actemra is medically necessary for 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 nephrology 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 59-year-old female enrollee requested authorization and coverage a of a CPAP device. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old male enrollee requested inpatient psychiatric hospitalization for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that documentation supports the medical necessity of a portion of the services.  This patient evidenced symptomatologies of parasuicidality and affective illness interwoven with his underlying characterological organization, addictive tendencies and chronic pain.  This patient had several concerning risk factors supporting initial admission.  He was suicidal and had recently lost two close relationships.  He had just returned to work and felt unsupported by his peers.  Additionally, he had chronic pain.  Thus, hospitalization was reasonably expected to improve his condition and prevent a more serious episode of illness.  While in the hospital, he received appropriate care delivered in accordance with a treatment plan.  He attended groups and individual cognitive behavioral therapy.  The inpatient team involved his family and aggressively adjusted his medications.  Subsequently, he was tolerating his psychotropic medications without side effect.  He was sleeping well at night and had no cognitive impairment or psychosis.  In sum, there was no acute psychiatric syndrome or contraindication to less restrictive treatment setting.  Thus, a portion of the services was medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Amitiza 24mcg capsules. The submitted documentation does not support that the requested medication is medically necessary. The requested Amitiza dose of 24mcg, twice daily, is supported for chronic idiopathic constipation only. The recommended dose for irritable bowel syndrome, with constipation-predominant, is 8mcg, twice daily. Furthermore, research shows that for constipation, the first line of therapy should be an osmotic agent, and then another type of laxative such as a stimulant laxative should be tried before a newer agent such as Amitiza is considered, as the newer agents have more adverse effects. The American College of Gastroenterology guideline for the treatment of irritable bowel syndrome recommends Amitiza among many alternatives for treatment, some of which have not been attempted.In this case, an osmotic laxative, Miralax, has not been successful, and the patient has also failed two advanced agents, Trulance and Linzess; however, a trial of a stimulant laxative has not been documented. Under these circumstances, a stimulant laxative should also be tried before a newer agent such as Amitiza is considered. Therefore, the requested medication, Amitiza 24mcg capsules, is not medically necessary for the treatment of the patients medical condition.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 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 patient has requested authorization and coverage for Gel One knee injections for both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a documented history of lasting relief from viscosupplementation of both knees with complete pain relief for six months. For these reasons, the requested Gel One knee injections for both knees are 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 orthopedic surgery 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 monthly home infusions of Privigen 10% dosed at 2 grams/kg over five days for initial dose, followed by 1 gram/kg over two days thereafter. Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of medications (Hovaguimian and Gibbons). Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to control the pain. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. IVIG has been shown to have significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are oftentimes small fiber polyneuropathies. Researchers provided Class IV evidence that IVIG is safe and effective for rigorously selected small fiber polyneuropathy patients with evidence to suggest an autoimmune causality. In this case, the patient has small fiber neuropathy and a history of autoimmunity. Her symptoms have not been controlled with conventional medical therapy. Based on the current medical studies, patients with autoimmune small fiber neuropathy are likely to improve clinically with IVIG. Given this support, the requested monthly home infusions of Privigen 10% dosed at 2 grams/kg over five days for initial dose, followed by 1 gram/kg over two days thereafter are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested monthly home infusions of Privigen 10% dosed at 2 grams/kg over five days for initial dose, followed by 1 gram/kg over two days thereafter are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 neurology 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 authorization and coverage for bilateral Orthovisc injections for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the current evidence-based medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with knee osteoarthritis who have failed conservative treatment.  Per the medical evidence, there is no maximum amount of injections established by high quality scientific evidence. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. He has undergone multiple prior series of viscosupplementation series with positive results documented in terms of significant pain reduction and improved function for at least six months. He is currently reporting progressive worsening of his knee pain and difficulty in ambulation. Viscosupplementation has been requested based on significant prior benefit and to delay total knee replacement. There is sufficient support for the requested services in this clinical setting.  All told, the requested bilateral Orthovisc injections are medically necessary for the 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 orthopedic surgery 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 three uninterrupted cycles of residential treatment center services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation supports the medical necessity of a portion of the requested services. Considering this case in its entirety, in particular the severity of symptoms and poorly developed sense of self, a time-limited course of residential treatment is medically necessary at this time. In the absence of a meaningful intervention, the distress stemming from the patients multitude of unresolved intrapsychic conflicts will more than likely culminate with a crisis-related hospitalization.  However, this should be framed as a brief, sub-acute, stabilizing intervention that prepares the patient for long-term outpatient care, coordinates multidisciplinary aftercare planning and facilitates a sustainable supportive living residence. In sum, it would be premature to approve a three-month residential admission at the outset. An initial four-week residential admission would be safe and reasonably expected to improve the patients condition. A longer admission would be contingent upon clinical reassessment, patient needs and appropriateness of the requested services in the context of evidence-based practice standards. Therefore, four weeks of residential treatment center services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Upheld

A 56-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) scan for vertebral fracture assessment for evaluation of her medical condition. Findings:  Three physician reviewers found that there is no direct evidence in the medical literature which demonstrates that screening for vertebral fractures using DEXA improves the selection of patients for treatment and consequently reduces risk of future fractures. Conclusions about the utility of the test, given its diagnostic characteristics, must be placed in the context of the clinical use of the test in making treatment decisions. At present, the diagnostic performance of vertebral fracture assessment using DEXA has not been adequately evaluated.Current evidence consists of studies examining the diagnostic sensitivity and specificity of vertebral assessment compared to plain x-rays. The populations evaluated in these studies were osteoporotic, and may not generalize to the population subject to proposed screening for vertebral fractures with DEXA such as this patient. There is insufficient evidence that the vertebral fracture assessment accurately detects fractures in individuals without osteoporosis (see Ferrar and colleagues).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Venetoclax 100 mg daily. The U.S. Food and Drug Administration (FDA) has approved venetoclax for the treatment of patients with chronic lymphocytic leukemia. Venetoclax is an inhibitor of BCL-2, which is often seen in chronic lymphocytic leukemia and about 20% of myelomas. Vaxman and colleagues found that about 20% of myelomas exhibit the t(11;14) mutation, and these have been found to have high expression of BCL-2, which suggests that venetoclax is likely to be effective in this subset of patients (Kumar, et al.). Moreover, the NCCN has included venetoclax in its recommendations for treatment of myeloma patients with the t(11;14) mutation. This patient has multiple myeloma with t(11;14) deletion. Therefore, the requested venetoclax 100 mg daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested venetoclax 100 mg daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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.