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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that the requested treatment regimen of Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. 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. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed regimen of Harvoni is consistent with FDA guidelines and is medically necessary to prevent further development and progression of fibrosis due to ongoing HCV infection. All told, the requested Harvoni  is medically necessary for treatment of the patients hepatitis C virus.  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

This patient is a two-year, eleven-month old female with a diagnosis of Rhetts syndrome. Associated with the Rhetts syndrome is a seizure disorder and cognitive/developmental delay, which includes significant motor delay. The patient is able to stand independently while holding onto furniture, but cannot stand independently without support. She requires maximum assistance to ambulate and is currently taking two to three steps using a Rifton Pacer Gait Trainer. When ambulating, she does not respond to commands and does not walk with intention toward an object. The patient requires moderate to maximum assistance to walk with the ambulatory assistance device.  The Health Plan has denied authorization for the device based upon their determination that the patient cannot use it for its intended function. In this case the ambulatory assistance device is being used as exercise equipment and cannot yet be used as a functional mobility device. Consequently, by community standards it is not medically necessary.  The patients medical therapy unit can continue to provide the device during therapy sessions. If, at some point, the patient starts to use it independently in therapy, then the medical necessity of the ambulatory assistance device should be reassessed at that time.  Based upon the information set forth above, I have determined the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested general anesthesia for treatment of the enrollees dental condition. Findings:  The physician reviewer found that general anesthesia for pediatric dental procedures is considered to be a safe and effective practice.  General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients.  However, in this patients case, there is no clear documentation of the need for extensive dental work and/or mouth oral rehabilitation. There is no clear documentation of an examination by the dentist who is planning to treat this patient.  There is no documentation of a previous attempt or attempts at dental examination or attempts to provide dental care with any dentist or provider without success.  There is no documented evidence of a dental treatment plan.  Thus, there is a lack of support for the requested services in this clinical setting.  All told, the requested general anesthesia is not medically indicated for the 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 anesthesiology with sub-specialty certification in pediatric anesthesiology 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 is a 47-year-old male with a history of hepatitis B. He was initially treated with lamivudine until he started to develop resistance. He is currently being treated with Hepsera. The information provided indicates his liver enzymes have responded favorably to Hepsera. The Health Plan has denied coverage for Hepsera. The current standard of care for this patients hepatitis B is to continue treatment with Hepsera. Stopping Hepsera would increase the potential for the patient to have a hepatitis flare-up. A search of relevant literature reveals support for treatment with Hepsera with no end point in the treatment. Literature indicates that treatment is for at least one year with most patients requiring longer treatment and, importantly, the criteria for stopping treatment have not been established. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the corneal cross-linking for treatment of his keratoconus. Findings:  Two physician reviewers found that Corneal cross-linking is a U.S. Food and Drug Administration (FDA) approved procedure for corneal ectasia and post-refractive ectasia. The primary purpose of cross-linking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. The procedure involves soaking the cornea with riboflavin and the using ultraviolet (UV) light to create chemical bonds between collagen fibrils within the corneal stroma. This stiffens the cornea and halts the thinning that is seen with corneal ectasias. Prior to this treatment, patients with keratoconus who failed medical treatment and whose disease continued to progress would require surgical management with corneal transplantation. Multiple studies have demonstrated that patients who underwent corneal cross-linking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity. In addition, further studies have shown an overall decrease in the number of penetrating keratoplasties performed since the introduction of crosslinking. Given this patients intolerance to contact lenses, high astigmatism, and topography, as well as the progressive disease in the contralateral eye, corneal cross-linking was an appropriate treatment to halt the progression of his keratoconus prior to a more invasive procedure such as penetrating keratoplasty. Final Result: The reviewers determined that the service at issue was 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: Reviewers 1, 2, and 3 are board certified in ophthalmology and is 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

A 35-year-old female has requested Betaseron 0.3mg for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication.  The patient has a reported history of relapsing-remitting multiple sclerosis.  Her prior therapies are unknown, as is the degree of disease activity.  Interferons and Copaxone are first-line therapies for the management of multiple sclerosis and are indicated for individuals with active disease.  In this patients case, details regarding her medical course were not provided.  The medical records do not demonstrate that the requested medication is indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx-Melanoma gene testing services for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that found the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics. By Balch staging, this melanoma would be classified as stage 1A, with an expected ten-year survival of at least 88%. Decision Dx-Melanoma gene testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 90 to 97% chance of disease free survival at five years), or Class 2 (with a lower rate of disease free survival at five years). Researchers reported on 217 cases, with good correlation between prognosis and Decision Dx-Melanoma gene testing classification in patients undergoing sentinel node sampling. This patient has not had such sampling. It is not clear how the Decision Dx-Melanoma gene testing five-year data compares to the ten-year Balch data and whether it can be used to make meaningful clinical decisions. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 subcutaneous Gammagard for treatment of his common variable immunodeficiency disorder (CVID).  Findings:  Two physician reviewers found that the diagnosis of CVID requires significantly reduced total serum concentrations of immunoglobulin, low immunoglobulin A (IgA) and/or immunoglobulin M (IgM), poor or absent response to immunization and exclusion of other immunodeficiency states or causes. In this case, the patient is reported to have low total IgG, IgM and IgA, but none of the other criteria of CVID (Chapel, and Cunningham-Rundles).  Upon review of the medical records, the patients immune status has not been fully evaluated. Although the provider stated that there have been recurrent infections, there is no supporting documentation (CXR, CT chest, CT Sinus, antibiotic log) to confirm recurrent infections. Moreover, standard therapy for CVID is treatment with prophylactic antibiotic. In this patients case, there is no documentation of a trial of prophylactic antibiotics. Therefore, the submitted documentation does not indicate that the requested services will likely to be more effective for treatment of this patient than any available standard therapy. Final Result: Two reviewers determined that requested services are 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 allergy and immunology 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 45-year-old female enrollee requested authorization and coverage for high-dose chemotherapy and autologous stem cell transplant. The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees breast cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy; therefore, the review organization upheld the health plan's denial.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee requested laboratory testing for medical evaluation of the enrollees dyslipidemia.  Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to have been more efficacious than other available modalities.  This patient is low risk for cardiovascular disease based on Framingham risk assessment.  The medical record indicated that her lipid disorder is well-managed with medication and lifestyle modification without side effects.  Per the current guidelines, there is a lack of support for the laboratory testing requested.  Thus, laboratory testing was not likely to have been more effective than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee requested a 12-week course of Harvoni 90 mg/400 for medical treatment of her hepatitis C virus.  Findings:  Three physician reviewers found that review of the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient has HCV and is requesting treatment with a 12-week course of Harvoni. The patient has F2-F4 fibrosis by non-invasive testing with a documented viral load of 15 million IU/ml with a genotype of 1a. She has no significant contraindications such as illicit drug or alcohol use. All told, based on available records demonstrating the patients F2-F4 fibrosis and high viral load, the requested medication is medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Two physician reviewers found that based on this review of the available records and the medical literature on proton beam radiation therapy, the requested services are not likely to provide this patient with an improved health outcome when compared to standard alternatives. The patients history of diverticulosis is not sufficient justification for the use of proton therapy over standard treatment with intensity modulated radiation therapy (IMRT). The National Comprehensive Cancer Network (NCCN) guidelines state that proton radiotherapy should not be routinely used in the treatment of prostate cancer. Overall, there is a lack of evidence that IMRT would result in greater than normal expected side effects to the critical normal structures at risk. Further, there is no evidence submitted that proton radiotherapy would result in a clinically significant decrease in toxicity compared to treatment with IMRT. Therefore, in this clinical case, treatment with proton radiotherapy would not be more beneficial than standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for light treatment (ultraviolet B) system for use in the home (UVB narrow band phototherapy home booth for treatment of the enrollees vitiligo. Findings:  The 3 physician reviewers found that vitiligo is an acquired pigmentary disorder of the skin and mucous membranes characterized by circumscribed depigmented macules and patches that cause significant morbidity due to cosmetic disfigurement. Treatment for vitiligo is difficult and prolonged. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist, as not all patients respond to standard available therapies. Variables that affect the choice of treatment include the extent, distribution, and progression rate of the lesions. Medical treatments include topical corticosteroids and other topical treatments, such as Protopic. This patient has tried and failed the standard medical therapies. Vitiligo can be treated with narrow band ultraviolet B (NBUVB) and studies have shown its efficacy. Thus, NBUVB is an established modality for treatment of vitiligo. In sum, light treatment (ultraviolet B) system for use in the home (UVB narrow band phototherapy home booth) is likely to be more efficacious than the other modalities available for the treatment of this patients medical condition.  Final Result: The 3 reviewers determined that the requested equipment is 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 is board certified in dermatology 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 dermatology 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 dermatology 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for intraosseous basivertebral nerve ablation (Intracept procedure). Current medical literature supports the use of the requested procedure in leading to statistically significant improvement over standard therapies including physical modalities and injections. Truumees and colleagues report that in patients with chronic low back pain and Modic type 1 or type 2 vertebral endplate changes, treatment with minimally invasive radiofrequency ablation of the basivertebral nerve resulted in significant improvement in pain and function. The referenced articles do also indicate this procedure is not recommended in cases with radiculopathy present. In this case, the patient reports persistent non-radiating low back pain despite prior maximal conservative treatment. However, there is no recent physical examination presented within the last 12 months to document the absence of radiculopathy findings which would make the procedure contraindicated.  In this clinical setting, intraosseous basivertebral nerve ablation (Intracept procedure) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested intraosseous basivertebral nerve ablation (Intracept procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested lumbar spine surgery for treatment of her neck and back pain.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. A review of the medical records demonstrates that the patient has chronic back pain; however radiculopathy has not been established in this clinical setting as she has no symptoms or signs of a defined lumbar radiculopathy (Tarulli and Raynor). Moreover, the documentation submitted for review fails to show that the patient has received a detailed neurologic or physical examination. In addition, her pain generator has not been identified. The proposed surgery is not consistent with accepted standards of good medical practice. Furthermore, the patient fails to meet Milliman Care Guidelines (MCG) and National Imaging Associates, Inc. (NIA) guideline criteria for the proposed surgery which includes: neurogenic claudication, radiculopathy, failure to improve with at least 6 weeks of conservative therapy, cauda equina syndrome, spondylolisthesis and motor weakness. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition.