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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma Gene Expression Classifier test for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  A relatively new test, the Afirma Gene Expression Classifier test, helps determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, the Afirma Gene Expression Classifier test was likely to have been more effective than other methods of evaluating this patient.  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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for proton beam radiation therapy. Given the proximity to the heart, the exposure could cause long-term cardiopulmonary complications. Based on long-term follow-up in patients treated for Hodgkins disease with radiation, mediastinal radiotherapy significantly increases risks of myocardial infarction, congestive heart failure, and valvular disorders (Aleman, et al). Proton beam radiation therapy for the treatment of thymoma has been shown to be safe and effective (Vogel, et al). Accordingly, the proton beam radiation therapy provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Euflexxa injections. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested services. The current medical literature supports the use of viscosupplementation for osteoarthritis of the knees. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the authors, the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Campbell and colleagues noted that 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, the requested Euflexxa 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: The patient has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2a/c. 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin (Feld, et al; Foster, et al). For these reasons, Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 15-year-old male enrollee requested authorization and coverage of continuing inpatient residential services for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for the treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested services were medically necessary until 3/14/03.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old female enrollee has requested artificial disc replacement surgery for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the wrist. Review of the submitted clinical documentation does not support the medical necessity of the requested MRI of the wrist. Wrist pain is a common complaint. The American College of Radiology (ACR) has established Appropriateness Criteria to better guide clinicians in efficacious imaging. For chronic wrist pain with or without trauma, the ACR recommends first obtaining plain x-rays of the wrist, and they deem MRI as usually not appropriate. Once plain x-rays are obtained and are normal, the ACR indicates that MRI is usually appropriate. However, in this enrollee, the question is whether an MRI will provide information that will guide a clinical decision. An imaging procedure is only warranted if it will change management.  In this enrollee, there is no indication that the enrollee has ever undergone conservative management. Further, there is no indication that he has ever undergone a course of anti-inflammatory medications, rest, or physical therapy. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the enrollees 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Fentora for treatment of her medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Fentora has not been established. Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, long-term opiates are more likely to cause adverse outcomes. Other researchers reported that prolonged use of high dose, opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  Given the above, Fentora as requested is 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-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

The parent of a seven-year-old male enrollee has requested  for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  Two physician reviewers found that applied behavioral analysis (ABA) therapy has been shown to be effective in treating behaviors associated with ASD (Rogers and Vismara). Overall, the current scientific literature supports the use of ABA treatments based on operant principles of learning as more effective for reducing problem behavior than alternative treatments. A recent 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles (Dawson, et al.). In a review of 34 studies on early interventions in autism, Warren and colleagues concluded that studies of Lovaas-based approaches, early intensive ABA intervention variants, and the Early Start Denver Model, resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. As discussed by the National Research Council (NRC), the goals of ABA therapy are to improve cognitive flexibility, pragmatic language, and social functioning. The NRC further advocates in favor of ABA therapy for programming that is intensive, structured, individualized with explicit teaching of social skills, communication and learning to learn skills.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patients recovery environment was supportive and free from alcohol. Given the findings on the ASAM guideline, the RTC services provided from were not medically necessary for treatment of this patient. 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 with expertise in addiction 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

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that there is support for the requested Viekira Pak for patients with early stage disease.  According to the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons.  Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Therefore, the requested Viekira Pak is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for the treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including or Zepatier. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Zepatier is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his hepatitis C virus.  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. For patients with genotype 4 hepatitis C, AASLD/IDSA guidelines recommend daily Viekira Pak and weight-based ribavirin. This is based on the PEARL-I trial, in which treatment-naive non-cirrhotic patients with genotype 4 hepatitis C achieved sustained virologic response in 100% of patients after treatment. In addition, this regimen was well tolerated with no serious adverse events reported. Based on evidence of safety and efficacy in the published literature and clinical guidelines, treatment with Viekira Pak is medically necessary in this case. 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.Findings:  Two physician reviewers found that according to a study, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. 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. 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 Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C 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 treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.   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: Overturned

A 49-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that Lobular carcinoma in situ (LCIS) is a very well known entity which when present, even when treated, places the patient in a high risk category. There is no known increased risk for LCIS concerning a specific lesion, however, there is clear evidence that the breast parenchyma is at increased risk for the development of invasive cancer. It is well established that lobular carcinoma is usually difficult to see with conventional imaging studies such as mammography and ultrasound. In this case, since there is difficulty in reproducing the findings seen on prior MRI with a follow-up ultrasound, it is medically reasonable and prudent to re-evaluate the patient with MRI. Ultrasound or mammographic guided biopsy is not possible since the lesions of concern could not be seen on the follow-up ultrasound.  Thus, in this case due to the higher risk of breast cancer based upon the history of LCIS and the equivocal ultrasound exams, it is necessary to rule out breast cancer and the best procedure to perform at this point would be the MRI.