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

The parent of a 10-year-old male enrollee has requested speech therapy services for treatment of his autism. Findings:  The physician reviewer found that laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. Review of the available peer-reviewed medical literature indicates that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism spectrum disorders.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  In this patients case, Harvoni for 12 weeks is likely to prevent further damage of the liver and disease progression.  Per the guidelines of the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  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: The 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Assay for evaluation of the enrollees melanoma. Findings:  The physician reviewer found there is a lack of support for the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Therefore, DecisionDx-Melanoma Assay was not likely to have been of greater benefit than other available modalities for evaluating this patient. Final Result: Three reviewers 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for Synvisc injections for treatment of her left knee osteoarthritis.  Findings:  The physician reviewer found that Bellamy and colleagues demonstrated the usefulness of viscosupplementation in the treatment of osteoarthritis of the knee. Further, Dagenais documented modest, short-term reduction of pain and improvement of function in patients with mild to moderate osteoarthritis, with no clear superiority among different products. Waddell and Bricker noted that some reports have indicated continued pain relief from multiple courses of treatment however they caution that Synvisc is also associated with an increased incidence of adverse events. While Waddell and colleagues suggested that repeat use of Synvisc may be more successful in patients with a prior successful course of therapy, Gossec and Dougados found that treatment with hyaluronates to be more efficacious in patients without radiographically severe osteoarthritis, and in patients with only mild, or no effusion. Thus, Espallargues and Pons concluded that the available evidence is inadequate to establish the safety and efficacy of multiple courses of treatment with Synvisc viscosupplementation for management of knee arthritis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco. Findings:  The physician reviewer found that the Centers for Disease Control and Prevention (CDC) state that there is adequate support for short-term efficacy of opioids for reducing pain and improving function in non-cancer, nociceptive and neuropathic pain in randomized clinical trials lasting primarily =12 weeks. The American Society of Interventional Pain Physicians (ASIPP) guidelines for opioid therapy noted clinical evidence review found insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy. ASIPP guidelines recommend non-opioid pharmacologic therapywhen benefits outweigh riskscombined with non-pharmacologic therapy. In this case, the physical examination findings and imaging results do not support the continuation of opioid therapy. The medical records do not document an appropriate trial of non-opioid and non-pharmacological treatment for this patient which is consistent with current medical guidelines. Therefore, Norco 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 subspecialty certification in pain management 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 54-year-old female enrollee has requested for a laparoscopic biliopancreatic diversion with duodenal switch for treatment of her morbid obesity. Findings:  Three physician reviewers found that duodenal switch, open or laparoscopic, is a standard primary treatment for morbid obesity based on available medical evidence and standards within the field. It is endorsed by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS). The vertical sleeve gastrectomy is generally reserved as a staged procedure, as it is yet to be considered a standard primary procedure for morbid obesity. In the 1st ASMBS position statement from 2007, one of the indications for vertical sleeve gastrectomy is for high risk or super obese patients to then be converted later to either the Roux-en-Y gastric bypass or the biliopancreatic diversion with or without duodenal switch.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that review of the relevant scientific evidence demonstrates the use of mammography plus tomosynthesis in a screening environment resulted in significantly higher cancer detection rate and enabled radiologists to detect more invasive cancers. Available studies also show that double reading of 2D plus 3D significantly improves the cancer detection rate. Scientific data further indicates that integrated 2D and 3D mammography reduce false positive recalls. All told, the medical literature provides adequate data to support the addition of breast tomosynthesis to conventional mammogram due to improved cancer detection rate. Upon consideration of the submitted documentation and available peer-reviewed evidence, the service at issue was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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:   All three reviewers are board certified in radiology with sub-specialty certification in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks 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, Harvoni is a first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with viral load below 6,000,000 IU/mL can be treated with Harvoni for eight 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.  All told, Harvoni for eight weeks 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: 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 peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis  was likely to be more beneficial than any available standard therapy. 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: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee requested authorization and coverage of the medication Vioxx. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that the patient presents with F0-F1 fibrosis and based on this result anti-viral treatment is not clinically indicated at this time. A reasonable approach would be to follow the patient and perform serial measurements of fibrosis non-invasively on a yearly basis. Therefore, Viekira Pak is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested spinal fusion surgery at L4-5 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation for treatment of his lower back pain. Findings:  The physician reviewer found that definitive indications for spine fusion include instability secondary to trauma, tumor, or infection, or iatrogenic causes. Spine fusion may be indicated in spondylolisthesis, abnormal movement with appropriate pain or neurologic deficit or mechanical pain. It is rarely indicated in the presence of abnormal radiographic results without appropriate clinical findings. Diffuse low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion. For non-radicular back pain with degenerative changes, fusion is no more effective than intensive rehabilitation, as noted by Chou and colleagues. Arthrodesis has a poor success rate when used to treat back pain associated with multilevel disc degeneration seen on MRI. Fusion of multilevel disease is associated with severe complications in up to 50% of cases, and it has a revision rate of 38%, as noted by Rollinghoff and colleagues. Studies have shown conflicting results, and there is need of further studies to permit firm conclusions.  In this case, there is a lack of documentation of indications to support a spinal fusion at the L4-S1 levels.  Thus, spinal fusion surgery at L4-5 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer. Findings:  The physician reviewer found that currently there is evolving evidence of the utility of breast cancer screening using MRI in certain subgroups of patients. The consensus is that MRI has a role in screening patients with a calculated lifetime risk of developing breast cancer of greater than 20-25%. While this particular patient does have a first degree relative with breast cancer, the practice guidelines indicate that a strong family history usually refers to at least 2 first degree relatives or a known BRCA1 or BRCA2 genetic mutation. Although this patients dense breast tissue may limit findings on mammography, she is not known to have at least 2 first degree relatives with breast cancer or a documented BRCA genetic mutation. As such, there is inadequate evidence establishing the medical necessity of the MRI screening performed for this patients evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg-100 mg for 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 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her 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 should be treated except those with limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per 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 8 weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings: Three of the three physician reviewers found that the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Advanced lipid testing measures subpopulations of lipoproteins and apolipoproteins which include lipoprotein(a) (Lp[a]), apolipoprotein A-I (ApoA-I), apolipoprotein B (ApoB), and measures of lipoprotein particle composition such as LDL and HDL particle number and particle size. Guidelines from 2013 do not recommend advanced lipoprotein testing which includes ApoB for cardiovascular risk assessment. At this time, the clinical utility of using the advanced lipid testing for assessment of cardiovascular risk is unclear. There is also a lack of clinical documentation to support the indication for advanced lipid testing for this patient. Therefore, the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three of the three reviewers determined that the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment 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 internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, and all three 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.