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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation for her breast cancer screening. Findings:  Three physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, considering the prior history of calcifications and that this study was performed in part to evaluate those calcifications, it was reasonable to perform tomosynthesis to separate out the overlapping structures.  In spite of the fatty density of her breasts, especially when the prior mammogram was not immediately available for comparison, tomosynthesis allows the possibility of demonstrating an otherwise occult tumor, by better delineating the calcifications and excluding an associated mass. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Xolair 150mg Vial; QT 2, days 28, total fills 12. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic idiopathic urticaria. A review of the record indicates that the enrollee has been diagnosed with chronic idiopathic urticaria and allergic rhinitis. The enrollee has a history of chronic almost daily urticaria since 2014 and that failed to respond with significant improvement from first and second-generation antihistamines. The provider reported the enrollee is doing much better on Xolair, only having a few mild episodes, taking cetirizine as needed only and is no longer needing daily antihistamines. The provider also reported the enrollee is underweight due to food restrictions, but is able to eat some histamine foods and is gaining weight since starting Xolair. The provider is recommending continuing Xolair and following up in six months.The American Academy of Allergy, Asthma, and Immunology (AAAAI) Practice Parameters for treatment of chronic urticaria states that Xolair is indicated for the treatment of refractory chronic urticaria that is unresponsive to conventional therapy. In the case of this patient, medical chart documentation indicates that the patient did not respond to conventional therapy with first or second generation antihistamines (Benadryl and Zyrtec), and H2 antihistamines (Ranitidine), and leukotriene antagonist, (Singulair), per clinic notes. The provider is seeking to lower the overall load of antihistamine for the patient and this is supported by documentation stating that there are suboptimal responses (and chronic almost daily hives) on conventional antihistamines and provided those dates on therapy. Additionally, the provider documented that the enrollees hives are significantly improved, and effectively controlled with Xolair therapy since starting, supporting the continued use of Xolair. 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 allergy and immunology, and pediatrics 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 48-year-old female enrollee requested authorization and coverage of abdominoplasty. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees excess skin status post gastric bypass surgery. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee requested authorization and coverage of Intensity Modulated Radiation Therapy (IMRT). The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment 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. AASLD/IDSA guidelines state that 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. The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, this patient should be approved for Harvoni to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease. 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

The parent of a 16-year-old enrollee has requested a formal dialectical behavioral therapy program which includes specific essential components for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although this patient requires more comprehensive treatment services to address their disease burden, the specified program central to this dispute is not medically necessary at this time.  Considering the multiple therapeutic foci, such a setting represents a safe and more appropriate placement than a DBT program at this time.  An inpatient program would be reasonably expected to improve the patients condition and prevent a more serious episode of illness.  The setting would also afford the opportunity for development of a multifaceted treatment plan, which may very well include elements of DBT in addition to other psychosocial and possibly pharmacological interventions, to facilitate harmonious and autonomous functionality in the least restrictive setting.  In sum, based on the documentation provided in context of relevant peer-reviewed literature and community treatment standards, a DBT program as requested is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 67-year-old male enrollee has requested Crestor 10mg/day for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that this patient has developed intolerant side effects to a formulary statin (Zocor). The patient has hypercholesterolemia and has responded to Crestor without reported side effects. The disputed therapy is well within the standard of care. Crestor is medically indicated and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.   Findings:  The physician reviewer found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. Final Result: Two of the three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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 parent of an enrollee has requested vision therapy and accompanying equipment for a vision therapy home exercise program for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that this patient has reading problems which may be partly related to convergence insufficiency.  In this patients case, it is appropriate to treat the convergence insufficiency.  In patients who have failed standard therapy, such as pencil push-ups, office-based vision therapy has been shown to be effective.  However, there is a lack of evidence indicating that the home equipment offers additional benefit over standard home exercises. Therefore, the superior efficacy of the requested vision therapy has been established.  However, the accompanying equipment for a vision home exercise program is not likely to be of greater benefit than other treatment options.  Final Result: Two reviewers determined that a portion of the requested services and equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:  All three reviewers are board certified in ophthalmology 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

The enrollee is requesting authorization and coverage for Belsomra, 10mg at bedtime (30 tablets/30 days). The enrollee has a medical history of postural orthostatic tachycardia syndrome, connective tissue disease, Raynauds syndrome, fibromyalgia, migraines, and insomnia. The medications that the enrollee took were ineffective, resulted in side effects, or caused withdrawal symptoms. The enrollee reports that Belsomra is one of the only sleep medications that have effectively helped her sleep without side effects. A recently published, randomized crossover study showed the use of Belsomra in fibromyalgia enrollees increased sleep time and reduced wake-after-sleep onset, compared to placebo. As she has tried so many medications, including those on the approved medication list, and has tolerated and benefited from Belsomra, it is appropriate for her to take Belsomra. It does have potential addiction problems, but she has not displayed any such tendency.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement for continued acute inpatient psychiatric treatment. Findings:  The physician reviewer found that the discharge summary documented that the patient was not unsafe and was considered a leader among his peers.  There were no major medication changes other than changing his lorazepam from every night at bedtime to an as needed basis.  The patient's neurological consultation and electroencephalogram did not uncover any pathology.  There were no special treatments that were administered during this time which required acute inpatient level of care.  The current medical evidence does not support the services at issue in this clinical setting.  All told, continued acute inpatient psychiatric treatment was not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections.Findings:  Three physician reviewers found that there is sufficient support for the requested services in this patients case. Botox is an effective modality in the management of chronic migraine. Repeated Botox injections have been shown to be safe and well-tolerated. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. This patient fits the criteria for chronic migraine. Additionally, she has failed a large number of therapies. Therefore, the requested Botox injections are likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 37-year-old woman with breast implants. She states that she was involved in a motor vehicle accident in November 2002. The enrollee indicates that her left breast implant was displaced by a shoulder belt during the accident. A breast exam in March 2003 was unremarkable for significant abnormalities. It appears the patient underwent a procedure several years ago to reposition her left breast implantation more laterally. The submitted photographs show lateral distortion of the left nipple. The Health Plan indicates the requested procedure is cosmetic in nature and is not medically necessary.The Health Plans denial should be upheld. The patient indicates that her condition was caused by a seat belt during a motor vehicle accident in which she was a passenger but there is not sufficient evidence that the patients problem is related to a seat beat injury. In addition, the submitted records indicate the patient had previously undergone a secondary augmentation of the right breast so it appears she has had prior problems, which necessitated cosmetic revision surgery prior to her motor vehicle accident. Furthermore, the requested procedure has been proposed to correct a breast implant, which is not a structure of the body. Moreover, removal of the implants has been offered by the Health Plan.Based upon the information set forth above, I have determined that the requested procedure is cosmetic in nature and is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested Sovaldi (sofosbuvir) 400 mg tablets and Olysio (simeprevir) 150 mg capsules for 12 weeks for treatment of his hepatitis C virus. Findings:  Two physician reviewers found that the requested medication combination of Sovaldi and Olysio are not likely to be more effective for this patient than other available options. The proposed combination treatment of simeprevir and sofosbuvir is not approved by the U.S. Food and Drug Administration (FDA) for treatment of the patients medical condition. Although the requested treatment of simeprevir and sofosbuvir has been suggested by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines it has not been studied in a large phase III trial. As such, the request for Sovaldi (sofosbuvir) 400 mg tablets and Olysio (simeprevir) 150 mg capsules for 12 weeks is not likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a history of pulmonary hypertension, emphysema and cardiomyopathy with an ejection fraction of 35% and an increase in her wedge pressure. No background data related to the patients diagnosis of emphysema is included and her hypertension (pulmonary) is described only as mild to moderate with no number value assigned.  The patients provider did not indicate a value for left ventricular end diastolic pressure and increased wedge pressure was not included as one of her diagnoses. The patients provider requested authorization for Revatio. The Health Plan denied the request based upon a determination that the medication is not medically necessary for treatment of the patients pulmonary hypertension.Significant pulmonary hypertension is seen in only about 5% of patients with COPD emphysema and typically does not require therapy. Sleep disordered breathing could also be a factor in the patients pulmonary hypertension but the issue is not discussed in the progress notes that were made available. It would appear at the very least that the patients left ventricular failure is partially responsible for her pulmonary hypertension. Based upon the information provided, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested X-stop implantation for the treatment of his lumbar spinal stenosis.  Findings:  Two physician reviewers found that while the X-Stop interspinous distraction device for treatment of neurogenic intermittent claudication has been used recently as a less invasive type of operative procedure in patients with spinal stenosis, there are no good long-term studies documenting the efficacy of its use.  The gold standard of care for this problem is spinal decompression.  Though the X-Stop procedure is less invasive, this does not mean that it is specifically indicated without long term trials and research. There are no documented clinical benefits or long term efficacy of the interspinous distraction device noted in the literature, and the procedure is therefore felt to be investigational until its efficacy and safety can be proven.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female has requested coverage for past assay laboratory testing (chemosensitivity and chemoresistance) for evaluation of her carcinosarcoma of the uterus.  Findings:  The physician reviewer found that uterine carcinosarcoma is a neoplasm of an endometrial epithelial cell that shows sarcomatous differentiation.  Surgical excision is an important initial treatment, and chemotherapy and radiation are current standards of care in the adjuvant setting.  The tumor is too rare to expect randomized clinical trials data, although current standard chemotherapy regimens include cisplatin, ifosfamide, and mesna.  In vitro drug testing on tumor cells prior to applying chemotherapy is an attractive idea, but it is difficult to put into clinical use.  A thorough evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004.  In their review of this technology, the panel concluded that such in vitro drug testing should be limited to clinical trials.  The Physician Data Query of the National Cancer Institute does not specifically recommend the Chemo FX assay to direct therapy.  The current medical evidence does not support the testing at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old woman who developed breast cancer at a relatively young age. She has a family history of breast cancer. She is requesting authorization for BRCA1 and BRCA2 genetic testing. The Health Plan has denied this request on the basis that genetic testing is not medically necessary in this case.BRCA testing is a means of determining whether a patient carries a gene mutation. Carriers of a mutation have an extremely high risk of developing both breast cancer and ovarian cancer. Patients found to have such a mutation often consider preventive surgical removal of ovaries and/or breasts. This patient who developed breast cancer at a young age also has a significant family history of breast cancer. BRCA testing would provide additional information as to whether she is at increased risk of ovarian cancer, a disease that lacks good screening tools. Given that she has multiple family members with a history of breast cancer, BRCA 1 and BRCA 2 genetic testing is medically appropriate and indicated. Therefore, I have determined the requested genetic testing is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.