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

The enrollee requested wireless capsule endoscopy. She has a history of abdominal pain. She experienced constant pain between her shoulder blades and frequent eructation and epigastric discomfort to the left upper quadrant, which did not respond to proton pump inhibitors or over-the-counter simethicone. An upper endoscopy was normal. A computed tomography scan noted a seven millimeter structure the distal ileum, which may represent bowel or a polyp. The gastroenterologist recommended a colonoscopy to evaluate the area in the distal ileum, with a follow-up capsule endoscopy. The wireless capsule endoscopy noted no evidence of a small bowel lesion or polyp, but detected a small foreign body in the distal small bowel. The gastroenterologist indicates the procedure was necessary due to the lesion on the distal ileum noted on the computed tomography scan. A colonoscopy showed moderate diverticulosis. The colonoscope reached 30 centimeters into the distal ileum but no lesion was found. The physician believes only wireless capsule endoscopy could provide diagnostic imaging of the small intestine; an anatomic site that has proven peculiarly difficult to visualize.  This enrollee had a seven-millimeter structure noted on the computed tomography scan, which was investigated via a colonoscopy, but no lesion was found. The next evaluative step is a capsule endoscopy. The indications for video capsule endoscopy of the small bowel are evolving. The primary indications are to evaluate for small bowel bleeding in adults, for the diagnosis of suspected Crohn disease, and for the diagnosis of small bowel tumors.  The medical literature indicates guidelines recommend capsule endoscopy for patients with suspected, known, or relapsed Crohns disease when colonoscopy studies were negative in order to determine the presence of active Crohn's disease. It is also used for surveillance in patients with polyps other small-bowel cancers. Capsule endoscopy is described as a technology developed for the endoscopic exploration of the small bowel. This technology has been refined to provide the ability to view different parts of the gastrointestinal tract. This enrollee has a lesion, which could not be identified by colonoscopy. Video capsule endoscopy provides an expanded range of endoscopic examination of the small bowel. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three 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

A 45-year-old female enrollee has requested Botox injections for treatment of the enrollees chronic migraines.  Findings:  Two physician reviewers found that although Botox has not been established as a first-line therapy for all headaches, there is adequate literature supporting its use in well-selected patients who have been refractory to standard treatments. As recently noted by Dodick and colleagues, The pooled PREEMPT results demonstrate that onabotulinumtoxinA is an effective prophylactic treatment for chronic migraine. Overall, the authors concluded that, OnabotulinumtoxinA resulted in significant improvements compared with placebo in multiple headache symptom measures, and significantly reduced headache-related disability and improved functioning, vitality, and overall health-related quality of life. Repeat treatments with onabotulinumtoxinA were safe and well tolerated. In this particular case, the patient has failed multiple medications including abortive and preventative therapies. Given her failure on other medications, a trial of Botox for this particular patient is medically indicated and likely to provide her with superior results to conventional modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested proton beam therapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that this patient has very early stage prostate cancer, and he was presented with several treatment options. The superior efficacy of proton beam treatment in this clinical situation has not been established by randomized trials.  Slater and colleagues showed that proton beam therapy yielded disease-free survival rates comparable with other forms of local therapy, with minimal morbidity.  The treatment was well-tolerated and was capable of producing biochemical disease-free survival rates equivalent to those achieved with other treatment methods.  However, at this time, the current medical evidence has not proven that the requested proton beam therapy is likely to be of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee requested authorization and coverage of enhanced external counterpulsation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees angina pectoris.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: Experimental/Investigational
Decision: Upheld

Physician #1:  The patient is a 53-year-old woman with refractory ovarian cancer in the lungs and abdomen. The patients provider has recommended treatment with Avastin. The Health Plan has denied coverage for Avastin on the basis that there is insufficient peer-reviewed medical literature establishing the efficacy of Avastin in this clinical setting.Review of the scientific literature reveals only a single case report regarding the use of Avastin in advanced refractory ovarian cancer. This does not meet accepted criteria for approval of a new therapy. The use of Avastin in ovarian cancer remains of proven benefit. There is insufficient safety data and a high observed incidence of visceral perforation with the therapy. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #2:  The patient is a 53-year-old woman with recurrent epithelial ovarian cancer. Treatment has included carboplatin, Taxol and topotecan followed by tamoxifen, carboplatin, Taxol, cisplatin, gemcitabine, and Doxil. The patient has experienced a recurrence in her abdomen and multiple lesions in her lungs. Her oncologist has recommended the use of Avastin. The Health Plan considers Avastin experimental for treatment of ovarian cancer.To date, there is insufficient published evidence on the use of Avastin for ovarian cancer. Additionally, it has not been approved by the Food and Drug Administration for this indication. There is no data demonstrating it is more effective than any other third or fourth line agent for ovarian cancer including altretamine, which the patient has not yet received. Accordingly, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #3:  The patient is a 53-year-old woman with refractory ovarian cancer. She is status post multiple chemotherapy regimens. She has requested authorization for treatment with Avastin. The Health Plan has denied the patients request indicating that the requested therapy is considered investigational.Avastin remains experimental/investigational in the management of ovarian cancer. Although there are some phase II trials suggesting a benefit, a formal report is soon to be published indicating an increase in risk of bowel perforations with Avastin. Furthermore, other standard options are available in this case including CPT-11, oral etoposide, and navelbine. For these reasons, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female who has a history of depression, polysubstance abuse, cutting behavior, suicidal ideation, bulimic behavior, legal problems and parent-child relational problems. Apparently her drug use escalated and she was admitted to residential treatment in September 2004 with diagnoses of major depression, ADHD, parent child relational problems, and marijuana dependence. She had a GAF score of 40 and a diagnosis of bipolar disorder was also suggested. The patient continued to receive residential treatment services until March 2005 when she transitioned to a partial hospitalization program.  The Health Plan has denied reimbursement for the admission to residential treatment and the services provided from September 2004 through March 2005 based upon their determination that neither the admission nor the continued stay were medically necessary.Upon review of the submitted clinical evidence, residential treatment was medically indicated because it is unlikely that a less intense level of care would have been adequate or appropriate given the state of the patients drug use and parent-child relational problems. Although the patients admission to residential treatment was justified, she was sufficiently stable by January 2005 to warrant treatment at a lower level of care. The submitted medical and nursing notes do not justify residential treatment services beyond 2004. Significant progress in addressing the patients issues had been made by years end. Although treatment at the residential level was continued until March 2005, the patient no longer met medically necessary criteria for this level of care. Therefore, I have determined the services provided from September 2004 though December 2004 were medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg (one tablet per day) for 12 weeks for treatment of the enrollees hepatitis C virus.  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 treatment naive genotype 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 400-100 mg (one tablet per day) for 12 weeks 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a transgender female who was diagnosed with gender dysphoria. It was noted that the patient had significant anxiety and depression due to the incongruence between her anatomy and her gender identity. The patient has requested authorization and coverage for any or all facial feminization surgeries.  At issue in this patients case is whether any or all facial feminization surgeries are medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that a nationally recognized health organization states that gender affirming/confirming surgery, plays an undisputed role in contributing toward favorable outcomes. Medically necessary gender affirming/confirming surgical procedures include facial plastic reconstruction. Facial feminization surgery is associated with improved mental health quality of life in transgender patients.  Medical evidence supports the requested services in this clinical setting. Therefore, any or all facial feminization surgeries 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of her medical condition.   Findings:  The physician reviewer found that in the Argoff review article, noting specifically chronic non-cancer pain, short and long acting opioid have been found to be effective. The review also noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. However, in this case, using the opioid risk tool (ORT) evaluation with the current notes provided, this patient is at high risk. The patient has documented chronic headaches, back pain, and dysmenorrhea but she also presents with a history of behavioral health issues, drug abuse, and post-traumatic stress disorder from prior events in her life. The patient only recently completed chemical dependency recovery and while opioids may be considered a part of standard of care when treating chronic pain conditions, opioids are considered to be highly addictive. Therefore, in light of the submitted documentation and the patients medical history, the requested medication is not medically necessary for 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A sixty year-old female diagnosed with breast cancer is requesting authorization of an Oncotype DX assay.Reviewers Findings:  The reviewing physician found that the Oncotype DX tumor assay score quite accurately predicts the risk of recurrence of the cancer within ten years, if the patient is treated with hormonal therapy as the sole systemic treatment.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested a 12-week course of Sovaldi in combination with ribavirin for treatment of his hepatitis C virus (HCV).   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication combination. At this time there is a lack of clinical documentation that shows the patient has significant liver disease. An assessment of fibrosis is necessary as part of the treatment process as there is no advantage in treating patients with minimal or no fibrosis. Acceptable testing includes liver biopsy, transient elastography, and serum markers for fibrosis. In addition, the value of treatment is unclear in individuals with minimal or no fibrosis with respect to long-term outcomes. In sum, based on the medical records submitted for review, the patients request for Sovaldi and ribavirin is not medically necessary. Therefore, the medical necessity of the requested medication combination has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 31-year-old female enrollee has requested for polydynamic therapy (Blue Light therapy) for the treatment of her cystic acne. Findings:  Three physician reviewers found that the Journal of the American Academy of Dermatology recently published guidelines for the treatment of acne vulgaris and Blue Light therapy is not considered standard of care. In addition, there is no evidence in the literature to suggest that Blue Light and Levulan would be more effective for this patient than standard acne treatments.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the requested medication, Stelara 90mg, every four weeks. The enrollee has Crohns disease and has previously failed treatment with Humira and Cimzia, despite dose optimization. The enrollee was started on Stelara and at his last visit he was doing well on the Stelara, with increased energy. He reported occasional episodes of diarrhea. Biopsies from a colonoscopy, to check for endoscopic remission, showed active inflammation in his small intestine. Thus, ustekinumab (Stelara) levels were ordered. His ustekinumab level was 3.5ng/ml. The enrollee has noticed recurrence of symptoms two to three weeks prior to his next dose. His physician recommended an increase in his ustekinumab dose from 90mg every eight weeks to 90mg every four weeks since the enrollee has already failed two anti- tumor necrosis factor (TNF) agents (Humira and Cimzia), and has had noticeable improvements on Stelara therapy.             In the medical literature, a study analyzed data regarding optimization to help enrollees with Crohns recapture Stelara response. The study analyzed 76 enrollees with active Crohns disease who had their dose escalate from 90mg every eight weeks to 90mg every four weeks because of loss of response or inadequate response. More than half of the enrollees recaptured response after optimization. Another study of subcutaneous ustekinumab for the treatment of anti-TNF resistant Crohns disease, indicated dose escalation was required in 47 percent of enrollees and was successful in 61 percent of those enrollees. In summary, the medical literature supports the use of Stelara with dose escalation giving it at an increased frequency. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of the enrollees hepatitis C virus.   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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Patients with diabetes mellitus are at risk for faster progression of fibrosis. Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety; the medication is U.S. Food and Drug Administration-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Feld, et al; Poordad, et al; Ferenci, et al). The AASLD and IDSA guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested treatment with Viekira Pak for 12 weeks 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: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested all four  quadrants scaled at one time in order to limit the enrollees exposure to one course of antibiotic therapy for treatment of her severe osteoporosis.  Findings:  The physician reviewer found that there is no supporting compelling medical need submitted for review that specifically states why the patient should be treated in one visit rather than over the course of two visits. There is also a paucity of current literature that identifies osteoporosis as a condition that should be treated with scaling and root planing in one visit. The current recommendations for standards of care by the American Dental Association and the American Association of Orthopedic Surgeons do not indicate that a patient with severe osteoporosis should receive scaling and root planing in one visit versus two visits. The literature does reflect that the scaling and root planing procedure does create a bacteremia greater than other dental procedures. It could be of concern to perform four quadrants of scaling and root planing as the bacteremia would be greater than two quadrants and could place the patient at risk for post treatment infection. In addition, providing local anesthetic to all quadrants of the mouth places the patient at risk for iatrogenic injury to the mucosal tissue and tongue while the patient is numb. All told, the requested antibiotic therapy is not supported as medically necessary for treatment of this patients medical condition.