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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for a consult regarding a bilateral mastectomy and male chest reconstruction, and for a bilateral mastectomy and/or male chest reconstruction. The enrollee is a male who was treated by a psychiatrist for gender dysphoria, anxiety, and panic disorder. His secondary sex characteristics cause him to feel anxious and depressed. He binds his chest tightly every day. He has been taking oral contraceptives and progesterone. His current therapist has recommended bilateral mastectomy with male chest reconstruction. Records show the enrollee was previously evaluated by social work and found capable of making the decision to transition. This enrollee has many mental health issues; related to the gender dysphoria or not, they apparently first presented three years prior and the concern is whether these issues can be resolved while still an adolescent. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 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 hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Harvoni has been approved by the U.S. Food and Drug Administration for the treatment of patients with HIV and hepatitis C, genotype 1.  Per the medical literature, the treatment of patients with HIV and chronic hepatitis C coinfection should be initiated at an early stage, regardless of fibrosis, to prevent progression of fibrosis to cirrhosis.  All told, the requested Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Three 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C.   Two physician reviewers found that the medical evidence supports the requested medication in this clinical setting.  The current guidelines support treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  There is sufficient support for Harvoni for the treatment of this patient based on national guidelines.  All told, the requested Harvoni is medically indicated for the treatment of this patient.  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: All 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: Upheld

A 63-year-old male enrollee has requested a PET scan for an evaluation of his prostate cancer. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of PET scanning for the assessment of metastatic prostate cancer or for the assessment of response to chemotherapy. This patient is currently receiving chemotherapy, per the most recent medical notes submitted. If this patients disease is progressing, this can be documented by PSA testing or other imaging studies, such as a nuclear medicine bone scan or CT scan of the abdomen/pelvis. Current medical literature does not support the use of PET scanning in this clinical situation. The PET scan was not necessary as there are other well established diagnostic modalities available in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested implantation of an Inspire Upper Airway Stimulation Device for treatment of his medical condition.   Findings:  Two physician reviewers found that implantation of an Inspire Upper Airway Stimulation Device is not likely to be more effective for this patient than other available options. Although the device is U.S. Food and Drug Administration (FDA) approved for obstructive sleep apnea intolerant to CPAP, the amount of literature that supports its use is not substantial or convincing. Specifically, the studies have been small and not designed as a head to head comparison of more accepted therapies for OSA. The use of upper airway stimulation devices remains a new technology and will require ongoing review as new data emerges comparing the device to other more conventional forms of OSA therapy. For the reasons provided, the requested services are not likely to be more beneficial than standard medical therapy in this clinical setting. Final Result: Two 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: One reviewer is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested for Nexavar for treatment of her metastatic ocular melanoma. Findings:  Three physician reviewers found that sorafenib is a multi-targeted tyrosine kinase inhibitor and raf-kinase inhibitor that has been approved for the treatment of renal cell carcinoma and hepatoma. Raf kinase inhibitors are of interest in the treatment of melanoma, owing to frequent raf kinase mutations in melanomas. There is limited clinical data available regarding the activity of sorafenib in the treatment of melanoma. From the data that is available (Eisen, et al), there does not appear to be any significant activity in this disease.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested for a whole body Positron Emission Tomography (PET) scan for his medical condition. Findings:  Two physician reviewers found that it appears a colonoscopy is indicated to further assess the computed tomography findings. There are no findings to date to suggest an occult primary malignancy. As such, a PET scan is not the appropriate next step in the care and management of this patients erythroderma.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested a right knee brace for the treatment of the enrollees condition. Findings:  The physician reviewer found that the requested ACL brace for the right knee does not appear reasonable on a prophylactic basis for the patient.  There is no proven scientific benefit for prophylaxis against injury for patients at the high school level. The use of prophylactic bracing even at a more competitive level remains controversial. The brace would be completely unrelated to the patients prior patellar stabilization surgery. No bracing should be required at this stage postoperatively. For these reasons the brace cannot be justified.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his 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. In treatment-naive genotype 3 patients (regardless of interferon eligibility), therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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

A 65-year-old female enrollee has requested for Tarceva 150mg/day for treatment of the enrollees pancreatic cancer.   Findings:  Two physician reviewers found that there are few therapeutic options for metastatic pancreatic cancer.  Gemcitabine alone or in combination with capecitabine, cisplatin, or Tarceva would be considered standard treatment options. In patients who progress on front-line therapy, second-line options would generally be felt to be active agents to which the patient has not yet been exposed.  Tarceva is FDA approved in combination with gemcitabine as the front-line treatment of metastatic pancreatic cancer. It has been studied beyond the front-line setting in a Phase II study with capecitabine, and found to be well tolerated with good clinical activity.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for the evaluation of her medical condition. Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The medical literature supports the services at issue in this clinical setting. The advantages of tomosynthesis relate to its ability to allow the differentiation of dense glandular tissue from the architectural distortion commonly associated with cancer. In this case, the architectural distortion secondary to prior lumpectomy sometimes makes the differentiation of post biopsy architectural distortion from cancer challenging. Tomosynthesis aids in this differentiation due to the tomographic quality of the technique. Therefore, the addition of breast tomosynthesis in this clinical setting was likely to be more beneficial for evaluation of this patient than any other technique. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment than PHP level of care. The patients risk of harm score is two (2), a low risk of harm. The patient has no history of suicidal ideation or suicide attempts. The patients functional status score is three (3), moderate impairment. The patient has had conflicts with her boyfriend due to drinking. Her boyfriend would drink alcohol and when the patient received treatment and committed to sobriety, the relationship ended. The patient did have a supportive family. The patients alcohol use was causing impairment in the patients ability to function in her daily life as she would isolate herself. The patients medical, addictive, psychiatric co-morbidity is three (3), significant co-morbidity. The patient has a co-morbidity of alcohol use disorder. She continues to use alcohol despite negative consequences. The patient has anxiety regarding financial stressors due to impulse spending. The patients recovery environment score is two (2), mildly stressful environment. The patient has conflicts with her boyfriend. However, the patients family is supportive. The patients level of support is two (2), supportive environment. The patients family is supportive. The patients treatment history score is two (2), significant response to treatment. The patient had limited prior alcohol use treatment. She had a good response to treatment at the residential and PHP level of care. She was psychiatrically and medically stable. Her engagement and recovery status score is two (2), positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. Based on these criteria, the patient has a total score of 16, which would meet criteria for treatment in a less restrictive environment. Therefore, the PHP services provided were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons tomosynthesis was likely to be more beneficial than any available standard therapy. 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 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: Upheld

An eighteen year-old male diagnosed with oppositional cannabis abuse, alcohol abuse and dysthymia is requesting authorization reimbursement for residential treatment services.  The patient was admitted to a residential level of care and remained at this level of care for a number of months.  Reviewers Findings:The reviewing physician found that there is no documentation of risk taking behaviors during the period at issue. There is nothing in the records provided to demonstrate that the patient required a 24-hour treatment setting or that he could not have been safely treated at a less acute level of care.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested artificial disc replacement for the treatment of his low back pain. Findings:  Three physician reviewers found that the requested procedure (artificial disc replacement) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Specifically, artificial disc replacement has not been shown in long-term peer reviewed studies to be more beneficial than standard fusion techniques.  Though early reports may be encouraging, the long-term data is not yet available. Research shows insufficient evidence to draw extensive efficacy/effectiveness conclusions comparing artificial disc replacement with a broad range of recommended treatment options, including conservative non-operative care since, other than spinal fusion, there are no direct comparison studies.  Therefore, it has not been established that artificial disc replacement is more beneficial in the long-term compared to fusion, and it is also impossible to determine comparisons with conservative non-operative care at the current time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services, including physical therapy, occupational therapy, and speech therapy. The records provided for review document that this patient presented with major trauma status. She sustained multiple fractures and organ damage, requiring blood transfusions. The patients providers state that she is not ready for home-based therapy. She remains at high risk for falls, is unable to adequate feed herself and take medications, and requires skilled rehabilitation services. All told, the requested SNF services, including physical therapy, occupational therapy, and speech therapy, 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 internal medicine with expertise in skilled nursing facilities 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 Harvoni for treatment of the enrollees medical condition.  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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed treatment with peg-interferon and ribavirin should be treated with Harvoni 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 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hormone implants for treatment of his hypogonadism.  Findings: The physician reviewer found that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The standard practice in the medical community is for evaluation to assess for low testosterone levels prior to the initiation of testosterone replacement therapy. The documentation submitted for review does not document the patients testosterone levels. In addition, there is no report of an evaluation regarding the patients low testosterone level. The records do not document if the patient has primary or secondary hypogonadism. All told, the hormone implants received were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three physician reviewers determined that the service at issue was 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: All three physician reviewers are board certified in urology 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.