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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Two physician reviewers found that when it comes to recommendations for treatment-naive chronic hepatitis C virus patients with genotype 1a, the national guidelines recommend daily Harvoni. Moreover, this patient has an extrahepatic manifestation of chronic hepatitis C virus, which is lymphoma. Hence, treatment is critical and should be prioritized as emergent. Accordingly, the requested course of treatment with Harvoni is supported as medically necessary. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing for hereditary breast and/or ovarian cancer syndrome (BRCA1/BRCA2) for evaluation of the enrollees risk for ovarian or breast cancer. Findings:  The physician reviewer found that There is a lack of support for the medical necessity of the requested services in this clinical setting. The American Congress of Obstetricians and Gynecologists criteria recommend a comprehensive initial screening for hereditary breast and ovarian cancer prior to initiating genetic testing. This patient does not meet the criteria recommended by these guidelines. The medical literature supports genetic testing for patients who do not have a personal history of breast cancer if she has a first degree relative diagnosed with breast cancer below the age of 45. This patient is 51 years old whose mother had breast cancer at age 46. Additionally, this patient is not an Ashkenazi Jew, and there was no other cancer history in her family noted. In sum, genetic testing for hereditary breast and/or ovarian cancer syndrome (BRCA1/BRCA2) is not medically necessary for the 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 internal medicine with sub-specialty certification in medical oncology 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: A patient has requested reimbursement for genetic tests for Ashkenazi Jewish associated disorders that were performed on 11/03/17. Findings: The physician reviewer found that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. The patient is of Ashkenazi Jewish descent and should be offered certain screening tests. Some experts have advocated for a more comprehensive screening panel for those of Ashkenazi descent, including tests for several diseases that are less common. The following is a list of autosomal recessive conditions for which screening should be considered in individuals of Ashkenazi descent: Bloom, familial hyperinsulinism, Fanconi anemia, Gaucher disease, glycogen storage disease type I, Joubert syndrome, maple syrup urine disease, mucolipidosis type IV, NiemannPick disease, and Usher syndrome. Therefore, the genetic tests for Ashkenazi Jewish associated disorders that were performed on 11/03/17 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 49-year-old female enrollee has requested cervical disc replacement surgery for the treatment of her cervical radiculopathy. Findings:  Three physician reviewers found that there are as yet unresolved issues of long-term efficacy and long-term health outcomes for cervical disc replacement. FDA approval has been obtained contingent upon completion of a long-term study. The longest-term study published to date includes a two-year period of follow-up and demonstrates only non-inferiority when compared to more traditional cervical intervertebral disc arthrodesis, foraminotomy and discectomy. Furthermore, in the case of this patient, the patients provider noted in February 2009 that the specific levels responsible for the patients symptoms had not been adequately determined. They noted that the, Clinical scenario is too difficult to determine which level is a problem. The testing subsequent to this statement included EMG nerve conduction testing, which was reported to be normal and does not help in localization. The CT scan is consistent with the MRI findings but does not provide specificity as to level. All told, there is inadequate evidence demonstrating that cervical disc replacement is likely to be superior to standard therapies in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 72-year-old female enrollee has requested combination therapy of bevacizumab (Avastin) and paclitaxel (Taxol) for treatment of her recurrent refractory ovarian cancer. Findings:  Two physician reviewers found that this patients particular clinical situation makes her an appropriate candidate for the combination chemotherapy of Avastin and Taxol. According to nationally recognized treatment guidelines (National Comprehensive Cancer Network), the combination of Taxol and Avastin is a category one recommendation for the treatment of metastatic ovarian cancer. There is no evidence that there are other regimens that are likely to be more effective in this case than the proposed regimen of Taxol and Avastin. An article by Hurt, et al. showed sustained progression-free survival with Taxol and Avastin in patients with recurrent ovarian cancer. In sum, the combination of Taxol and Avastin is a medically reasonable option for this patient and should be covered by the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested a group 2 power wheelchair for medical treatment of his Charcot Marie Tooth disease. Findings:  The physician reviewer found this patient has a congenital peripheral neuropathy which has progressed over the past year to cause significant weakness and loss of sensation in the feet and right wrist. The providers agree that he cannot safely walk with assistive devices or control a manual wheelchair in a residential or community setting. All told, the patient meets the Centers for Medicare and Medicaid Services (CMS) criteria for use of a powered mobility device. Thus, the requested group 2 power wheelchair is supported as medically necessary for treatment of this patients 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 the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) has urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms especially in women with heterogeneously and extremely dense tissue such as in this case. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in biopsies, callbacks and increase in detection of small cancers. Thus, the inclusion of tomosynthesis as part of this patients screening mammogram was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone.  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 board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xigduo XR 10 mg-1,000 mg tablets. Xigduo is a combination of metformin and dapagliflozin, which is a member of the sodium-glucose transport protein 2 (SGLT2) inhibitors (Chrysant). The U.S. Food and Drug Administration (FDA) has approved canagliflozin, dapagliflozin, and empagliflozin for the treatment of type 2 diabetes mellitus. Researchers reported glycemic control benefits, weight reduction, and systolic blood pressure lowering with Xigduo for patients with type 2 diabetes. This patient has type 2 diabetes complicated by hypertension and dyslipidemia. Based on the chart summary from the provider and current medical literature, treatment with Xigduo is appropriate to manage this patients type 2 diabetes. Accordingly, the requested Xigduo XR 10 mg-1,000 mg tablets are 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 diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested a colonoscopy screening for medical evaluation of his risk for colon cancer given his family history of colon cancer. Findings:  The physician reviewer found that this patients personal risk for Lynch syndrome diminishes with every serial negative colonoscopy exam. However, two negative colonoscopies do not inoculate him against colon cancer and a five-year repeat colonoscopy is clinically appropriate given the patients potential risk. Thus, the available records support the medical necessity of the requested colonoscopy procedure for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested coverage for six months of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of function in older children with autism spectrum disorders, with the use of intensive ABA therapy (Sallows, et al.) The goals for older children are often to identify and remediate particular deficits, such as non-compliance with this patient. The requested duration of therapy is medically reasonable and appropriate for this patient based upon his documented deficits. Thus, it is medically necessary that this patient receive six months of ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a sixteen year-old female who has suicidal ideation with a severe oppositional defiant disorder are requesting reimbursement for residential treatment services.Reviewers Findings:  The reviewing physician found that according to the ASAM Adolescent Criteria and the standard of care for the treatment of substance abuse problems in adolescents, the patient did not demonstrate any behaviors that would require a residential treatment setting.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested the cool/ice unit intermittent limb compression device for medical treatment of her status post ankle fusion surgery.  Findings:  The physician reviewer found that the cool/ice compression unit was utilized after ankle surgery. The device is indicated to reduce swelling and pain. Block reports that cryotherapy and static compression is commonly used for acute injuries as this intervention is thought to be most effective if applied almost immediately after injury or at the conclusion of an operative procedure. There is also benefit noted in the post-operative period. In sum, despite the limited clinical records submitted, the device at issue was medically necessary for treatment this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for a full body MRI for evaluation of her medical condition. Findings:  The physician reviewer found that MRI imaging is usually performed on a certain body part or region (i.e., abdomen, pelvis, spine, knee, shoulder, brain or neck) when there is clinical concern of an underlying mass or internal derangement or to further evaluate an abnormality noted on another imaging study. Multiple imaging studies have shown no suspicious abnormalities. There is no medical evidence to support MRI imaging of the whole body.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Chantix for the treatment of his medical condition.  Findings: The physican reviewer found that per the medical evidence, smokers should be managed with a combination of behavioral support and pharmacologic therapy.  First-line agents for tobacco cessation include combination nicotine replacement therapy (transdermal nicotine patch combined with nicotine gum, lozenge, inhaler, and/or nasal spray), Chantix, and bupropion.  However, the use of Chantix in patients with a current unstable psychiatric status or a history of suicidal ideation is avoided.  Thus, combination nicotine replacement therapy is appropriate for patients for whom the safety of Chantix is a concern.  In patients with bipolar disorder, nicotine replacement therapy is a good first-line treatment.  The documentation submitted does not provide any history or details about his current psychiatric stability or any plan for monitoring for any behavioral changes and psychiatric symptoms while being treated with Chantix.  In this clinical setting, nicotine replacement therapy would be preferred over treatment with Chantix.  The documentation does not show he has failed treatment with nicotine replacement.  All told, Chantix is not medically indicated for the treatment of this patient.  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 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 Orthovisc injections for both knees. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections for both knees are medically necessary to treat the patients medical condition at this time.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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a bilateral knee magnetic resonance imaging (MRI). The American College of Radiology (ACR) appropriateness criteria for chronic knee pain notes that imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. While plain x-rays may be of limited value due to the menisci and ligaments not being visible, they may be used to assess the degree of degenerative disease and whether there are any acute bony structural abnormalities. In this case, plain x-rays demonstrated moderate-to-severe degenerative disease of the bilateral knees and described bone-on-bone osteoarthritis. In this clinical setting, while an MRI may demonstrate meniscal tears as well as ligamentous disruption, the status of the ligaments is irrelevant to the patients workup and management options, given that the plain x-rays demonstrated virtually complete loss of the menisci and severe arthritic change. Therefore, a bilateral knee MRI is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested Lasik surgery for the treatment of her headaches secondary to vision issues. Findings:  The physician reviewer found that the requested Lasik surgery for correction of refractive error is not medically necessary for this patient. There is no documentation provided that indicates this patients headaches are related to an ocular condition or her glasses. The providers notes state the indication for Lasik in this patient is not the headaches but the refractive error. While the patient states that she cannot wear contact lenses due to the curvature of her cornea, her ophthalmic examination revealed a cornea curvature that should be an easy fit for contact lenses despite her history of dry eyes. There is no documentation to suggest the patients facial pain is due to her glasses and if it is due to her glasses, there is no documentation of an adequate attempt at trying different styles of glasses that were fitted by certified opticians.