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

A 60-year-old male enrollee has requested Synvisc injections for treatment of his shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  The current medical literature does not support the requested Synvisc injections in this patients case.  Hsieh and colleagues compared the efficacy of intra-articular hyaluronic acid injections with physical therapy versus physical therapy alone for patients with adhesive capsulitis.  The authors reported that hyaluronic acid injections did not provide additional benefit for patients who were already receiving physical therapy.  Colen and colleagues conducted a systematic review of the use of hyaluronic for joints other than the knee.  The authors noted that there is a lack of evidence demonstrating that hyaluronic acid is superior over corticosteroids or other conservative therapies.  All told, the requested Synvisc injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that the medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with the two-dimensional technique alone.Final Result: 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: 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 Sovaldi and Daklinza for treatment of her hepatitis C. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  The guidelines cite data showing that delay in treatment may result in decreased survival.  For these reasons, the requested treatment with Sovaldi and Daklinza 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 medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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. Given the findings, the RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the breast. Findings: Three physician reviewers found that there is sufficient support for the services at issue in this patients case. While ultrasound may be beneficial for the evaluation of implant rupture, the utility of that technique is best for patients with saline implants. This patient has silicone implants which are difficult to evaluate with ultrasound due to the dense nature of the material. While ultrasound may have shown extravasated silicone, the possibility of intracapsular rupture would not have been addressed. MRI is the more definitive test in the evaluation of implant rupture and is more sensitive than other breast imaging techniques. Therefore, MRI of the breast 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: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Foundation One gene testing performed.Findings:  The physician reviewer found that Molecular profiling of an individuals cancer cells, as is done with the Foundation One assay, is an assay of genomic or molecular abnormalities.  The goal is to identify a target at which a specific treatment could then be offered. At this time, there is a lack of convincing evidence that the assay adds to the decision making ability to improve patient outcome. There are a variety of non-randomized trials exploring the value of molecular profiling that have not been convincing. A randomized trial  did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. All told, the superior efficacy of Foundation One gene testing performed  has not been established.Final Result: The reviewers  2 of 3 determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewer s 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  The physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Final Result: All 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: Physician reviewer number one, two, 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni is medically indicated for the 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 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 residential treatment for treatment of her behavioral health condition.  Findings:  The physician reviewer found that residential treatment was medically necessary for treatment of the patients medical condition. According to the medical literature, Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Based on the longitudinal history and medical documentation, the patient likely would have relapsed and required re-admission in the absence of residential programming. Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided during the disputed timeframe were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the peer-reviewed literature, the services at issue were medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that  breast tomosynthesis has been widely embraced by radiologists due to an associated decrease in callbacks and increase in detection of small cancers due to the tomographic qualities of the additional technique.  This allows the radiologist in many instances to sort out dense glandular tissue from underlying architectural distortion and mass, thereby improving the accuracy and confidence of the interpretation.  This is especially true in cases of very dense and heterogeneously dense breast tissue.  Thus, the addition of breast tomosynthesis was more likely of benefit to the patient than if the study had been done without the three-dimensional technique. Final Result: 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive, genotype 1a patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  This patient is ineligible for the alternative for genotype 1a due to a pre-existing medical condition, which can be exacerbated by ribavirin.  For these reasons, the requested treatment with Harvoni 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Based on the available documentation and current medical literature, proton radiation therapy is not considered the standard of care for this patients recurrent invasive squamous cell carcinoma. The American Society for Radiation Oncology (ASTRO) does not support the use of proton radiation therapy for management of pelvic malignancies outside the context of a prospective clinical trial. Currently, there are insufficient high quality clinical trials demonstrating improved health outcomes with use of proton beam radiation therapy in this setting. The standard of care remains intensity modulated radiation therapy for treatment of this patients recurrent disease. Therefore, the requested PBRT is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are 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 radiation 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AmniSure testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. AmniSure is not recommended as a first-line test. A prospective study found placental alpha-microglobulin-1 in cervicovaginal secretions is superior to conventional clinical assessment in the diagnosis of rupture of membranes. However, studies have also found false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. Given that the patients ultrasound did not show decreased amniotic fluid volume and she did not undergo standard testing prior to AmniSure testing, the testing was not medically indicated or likely to be more beneficial for evaluation of the patients medical condition than standard testing.  Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in obstetrics and gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for single-photon emission computed tomography (SPECT) scan. Findings:  Two of the three physician reviewers found there is a lack of support for the services at issue in this clinical setting. The liver/spleen scan crudely assesses whether the patient has portal hypertension, but does not clarify the cause of their medical condition. Based on this patients laboratory testing and imaging, there was no suggestion of underlying cirrhosis. Therefore, concern for portal hypertension was not a consideration. Thus, SPECT scan was not likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 61-year-old male enrollee has requested platelet rich plasma injection for treatment of his medical condition.  Findings:  Three physician reviewers found that platelet rich plasma injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed studies that provide long-term and randomized data necessary to establish the efficacy of platelet rich plasma in this clinical setting. A meta-analysis by Sheth and colleagues noted that the current literature is complicated by a lack of standardization of study protocols, platelet-separation techniques, and outcome measures. As a result, there is uncertainty about the evidence to support the increasing clinical use of platelet rich plasma and autologous blood concentrates as a treatment modality for orthopaedic bone and soft-tissue injuries. All told, there is insufficient outcomes data from high quality, well-designed studies to support the use of platelet rich plasma in this setting. As such, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.