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

A 61-year-old male enrollee has requested Harvoni for treatment of his hepatitis C genotype 1a.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose of Harvoni 90/400 mg is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.
Appeal type: Urgent Care
Decision: Upheld

A 47-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that the patient was suffering from chronic pain and narcotic addiction without any acute disorder. This clinical scenario does not meet the Prudent Layperson Standard for seeking immediate medical attention. The patient had normal vital signs and did not appear to be going through opiate withdrawal. Furthermore, opiate withdrawal is not a life-threatening disorder. It is unclear why the patient chose to go to an emergency department for her prescription refill given that it was a weekday, and she should have been able to reach her primary care physician or pain clinic physician for additional medications.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that the indications for a screening breast MRI are well established in the peer-reviewed medical literature. Screening breast MRI studies are appropriate for patients with a history of radiation therapy to the chest region as a young adult, for patients who test positive for BRCA mutation, for patients with a first degree relative with documented BRCA mutation and for patients with a calculated risk of breast cancer of 20-25% or greater. This patient does not have a history of radiation therapy to the chest wall. The patients BRCA mutation tests were negative. The patient does not have a first degree relative who has tested positive for BRCA mutation.  The patients calculated risk is less than 10% using the Gail model. The indications for a diagnostic breast MRI include inconclusive findings on mammography and/or breast ultrasound, new diagnosis of breast cancer, question of recurrent cancer versus scar and when there is concern of implant rupture. This patient does not have a personal history of breast cancer or breast implants.  The patients most recent mammogram and breast ultrasound were negative. In conclusion, this patient does not meet the accepted criteria for a screening breast MRI or a diagnostic breast MRI. All told, the requested breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a heart valve replacement using a catheter (transcatheter valve repair) for treatment of the enrollees mitral regurgitation and congestive heart failure (CHF). Findings:  Three physician reviewers found that this patient needs a mitral valve intervention considering her age and decline in her ventricular function. Mitral valve intervention would be expected to have the greatest long-term benefit before ventricular function further deteriorates. However, there is a lack of data demonstrating that the MitraClip is likely to provide a long-term advantage over a standard open heart mitral valve procedure with either repair or valve replacement. The MitraClip is U.S. Food and Drug Administration (FDA) approved for prohibitive risk patients. However, this patient, despite her comorbid health conditions, is not high risk with respect to standard open mitral valve procedures. Thus, the requested heart valve replacement using a catheter (transcatheter valve repair) is not 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 service 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: Reviewers 1 and 2 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing.  Reviewer 3 is board certified in thoracic surgery 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain.Findings:  The physician reviewer found that patient presents with a history of Morgellons disease with reported neurological symptoms. Morgellons disease is a dermatological condition characterized by the presence of multicolored microscopic fibers in skin lesions or lying under unbroken skin (Fesler, et al.). According to the best available scientific evidence, Morgellons disease is considered a dermopathy associated with tick-borne /disease. In addition to fiber production, some patients may experience stinging, biting, and crawling sensations. Systemic symptoms may include fatigue, joint pain, cognitive difficulties, and neuropathy (Middelveen, et al.). This patients provider has recommended evaluation of the patients Morgellons disease with MRI of the brain. However, the peer-reviewed medical literature does not recommend MRI of the brain as part of the routine evaluation of patients with Morgellons disease. Moreover, the records provided for review do not include details of the patients history, physical examination, or assessment of the patients symptoms to support an indication for evaluation with an MRI of the brain. For these reasons, the requested MRI of the brain is not medically necessary for evaluation of this patient.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee has requested lumbar spinal fusion from L5-S1/Axial Lumbar Interbody Fusion for treatment of her lumbar degenerative disc disease and lumbar spondylosis. Findings:  Three physician reviewers found that in the medical literature, the efficacy of spinal fusion in the management of chronic low back pain has been evaluated by Brox and colleagues in a randomized patient population to a program of cognitive intervention and exercises versus fusion with posterior transpedicular screws. Overall, there was no advantage over instrumentation and fusion versus the conservative treatment method. Similarly, Fairbank and colleagues compared an exercise program with fusion and found no significant difference in outcomes between the two cohorts. An additional evaluation comparing lumbar spinal fusion against nonsurgical treatment by Kwon and colleagues suggests that spinal fusion surgery has modest effects at best. This patients records document that she has undergone standard conservative therapies including pain clinic needle intervention treatments, which would be expected to provide only short-term benefits. The chart does not include any treatment with neurocognitive methods and the physical therapy approaches are limited to one year. Taking these factors together with the general considerations from the peer reviewed literature it is likely that the requested spinal fusion surgery will not be more beneficial for this patient than conventional modalities for management of her back pain.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old male with chronic constipation and/or irritable bowel syndrome (IBS) with constipation. He has failed to respond to traditional therapies. The patient has had documented response to use of Zelnorm. The Health Plan indicates Zelnorm is not medically indicated for the patient.Review of the submitted clinical information clearly demonstrates the patient responded well to Zelnorm after suboptimal response to other constipation therapies. FDA indications do not cover the use of many medications that are indeed standard and indicated therapies for a disease or symptom. FDA indications alone are never the basis for determining standard of care or appropriate use of an agent, but are only part of the information used in making this individual determination. Furthermore, Zelnorm has in fact received an FDA indication and labeling for chronic constipation regardless of gender. Thus, the patient meets the clinical indication for Zelnorm as well as the FDA labeling indication for use of this compound. Accordingly, I have determined the requested medication is medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested intensive outpatient treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that while this patient had persistent suicidal ideation, there is no indication of any plan or intent in the records provided and the treatment plan does not indicate a safety plan.  There is no evidence that the patients medications were being titrated or that she was significantly below her baseline. The American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective. While the clinical information supplied is limited in this case, it is noted that the patient had a regular therapist. Although the patient has a condition which will require ongoing treatment for the long-term, the records submitted do not demonstrate that her condition could not be managed in the context of outpatient therapy and medication management from the admission date onward. Furthermore, given the absence of current medical record documentation, the medical necessity of future IOP services has not been established. All told, there is insufficient evidence that IOP level of care for this particular patients clinical situation was and is consistent with APA practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Crestor 5 mg once a day, Relpax 40 mg once a day, Diovan HCTZ 80-12.5 mg once a day, and Klonopin 0.5 mg once a day. In this case, the patient has medical problems including hyperlipidemia, hypertension, migraine headaches and chronic twitching of the eyelid. The medications including Crestor (rosuvastatin), Diovan HCTZ (valsartan/hydrochlorothiazide), Relpax (eletriptan) and Klonopin (clonazepam) are medically appropriate treatment for her medical conditions. However, the records provided for review do not support the medical necessity of the brand name formulations of these medications. Specifically, the documentation does not report that the patient has experienced any adverse reactions to the generic equivalents of these medications. When the U.S. Food and Drug Administration (FDA) approves a generic drug product, it has met rigorous standards with respect to identity, strength, quality, purity and potency. Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product. The generic drug manufacturer must prove its formulation of the medication is bioequivalent to the brand name drug. Through review of bioequivalence data, the FDA ensures that the generic product performs the same as its respective brand name product. Therefore, the requested Crestor 5 mg once a day, Relpax 40 mg once a day, Diovan HCTZ 80-12.5 mg once a day, and Klonopin 0.5 mg once a day are not medically necessary for treatment of this patient. 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 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: The patient has requested authorization and coverage for tramadol hcl 50 mg tablets. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. For these reasons, the requested tramadol hcl 50 mg tablets are not medically necessary for 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 anesthesiology with sub-specialty certification in pain medicine 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 62-year-old male enrollee has requested CPT11 (Irinotecan) in combination with 5-FU and Leucovorin for treatment of his stage IV pancreatic cancer. Findings:  Three physician reviewers found that metastatic pancreatic cancer is one of the most difficult cancer types to achieve meaningful responses. The standard treatment agent has been Gemzar, but recently there has been a trend toward study of the combination FOLFIRINOX, which includes 5-FU, oxaliplatin, Leucovorin, and irinotecan (CPT 11). A similar combination was reported in a study by Conroy and colleagues in 2005 with promising results. In 2010, Conroy and colleagues presented their data to the American Society of Clinical Oncology (ASCO), demonstrating superiority over treatment with Gemzar. Subsequently, the group confirmed these findings in their 2011 publication. As this patient has already been treated with single agent, which he cannot tolerate, it is now appropriate to treat him with the rest of the FOLFIRINOX combination. Given the scientific data in support of its efficacy, the use of irinotecan in this clinical situation is likely to provide this patient with more benefit than any other proposed treatment.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male has requested occupational therapy for treatment of his autism. Findings:  The physician reviewer found that there is strong scientific evidence supporting the use of occupational therapy in the treatment of autistic children. Occupational therapy is often effective in reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al). May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing occupational therapy sensory integration techniques for autistic children. Their conclusion, based on the meta-analysis, was that this therapy is effective, but studies were inconclusive regarding the duration or the amount of occupational therapy necessary for positive effects. All told, occupational therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient level of care for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  The patient continued to have agitated aggressive behavior as his meds continued to be readjusted and he was prepared for discharge.  Discharge planning was actively taking place as the patient awaited transfer to a lower level of care. The services at issue during the dates of service in dispute were for appropriate and safe discharge planning.  All told, inpatient level of care was medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in child and adolescent 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: Upheld

A 44-year-old female enrollee has requested for a screening colonoscopy for evaluation of her colon. Findings:  The physician reviewer found that the  updated guidelines for colorectal cancer screen recommend that people with one first-degree relative with colon cancer or adenomatous polyps diagnosed at less than 60 years of age or two first-degree relatives diagnosed with colorectal cancer at any age, should have a screening colonoscopy starting at age 40 years or 10 years younger than the earliest diagnosis in their family, whichever comes first. Colonoscopy should be repeated every five years. People with one first-degree relative with colon cancer or adenomatous polyps diagnosed at greater than 60 years of age or two or more second-degree relatives with colorectal cancer should be screened as average risk persons, but beginning at the age of 40 years. The guidelines for colorectal polyp surveillance indicate that after a complete clearing colonoscopy done at the time of the polypectomy, a repeat colonoscopy should be performed in three years for patients at high risk for developing advanced adenomas. After a negative follow-up colonoscopy, subsequent surveillance intervals may be increased to five years.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the request for proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is some medical literature supporting the safety and efficacy of proton beam radiation therapy for the treatment of prostate cancer. However, there is a lack of randomized trials suggesting superior clinical outcome for prostate cancer over standard therapy such as intensity-modulated radiation therapy (IMRT). Additional studies for long-term safety and efficacy are needed comparing protons with photons for the treatment of prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines indicate that proton therapy is an option for prostate cancer, but no clear benefit over the existing therapy of IMRT has been demonstrated. Given the lack of peer-reviewed literature supporting proton radiation therapy for prostate cancer, the requested services are not 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 services are 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: Reviewers 1, 2, and 3 are board certified in radiation 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.