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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an epidural steroid injection for treatment of her medical condition.  Findings:  The physician reviewer found that the records provided for review do not support the requested epidural steroid injection as medically necessary for treatment of this patients medical condition. The patient has been treated with physical therapy. However, there is no documentation of a home exercise program or how long the patient was treated with physical therapy. The literature indicates that a home exercise program after physical therapy independent of an epidural can give a patient lasting results. In addition, the patient does not have any recent physical exam findings and imaging supporting a diagnosis of cervical radiculopathy at the C3-4 level, instead the physical exam and imaging supports a diagnosis at the C6-7 level. Therefore, the request for an epidural steroid injection is not medically necessary for treatment of this patients medical condition.   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 and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: 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: 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 the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis allows radiologists to differentiate dense glandular tissue from architectural distortion, thereby resulting in decreased callbacks and increased detection of small cancers.  The addition of breast tomosynthesis to two-dimensional screening mammography has gained worldwide popularity among radiologists.  Thus, the addition of digital breast tomosynthesis to the screening mammogram was likely of more benefit to the patient than had the mammogram been done without tomosynthesis.  Final Result: Two 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Two physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established and these guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), Apo-lipoprotein B, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (LDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment changes or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Further, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewers are 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 DecisionDx-Melanoma gene assay testing.  Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) Guidelines state that 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 (baseline) prognostic genetic testing of primary cutaneous melanomas (before or following sentinel lymph node biopsy) is not recommended outside of a clinical study (trial). Should a patient have high risk results, treatment and surveillance recommendations would unlikely be altered. Therefore, the services in issue were not likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services in issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 24 week course of Sovaldi and ribavirin for treatment of his chronic hepatitis C virus genotype 3a. 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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. The guidelines recommend treatment with daily Sovaldi and weight-based ribavirin for 24 weeks for treatment of genotype 3 hepatitis C in interferon-ineligible patients. This is based on the U.S. Food and Drug Administration (FDA) approval which recommends 24 weeks of therapy and on the VALENCE trial. The trial found a higher rate of sustained virologic response in patients who had 24 weeks of therapy than patients who had shorter therapy in the FISSION and FUSION trials. Consistent with these findings, the requested 24 week course of Sovaldi and ribavirin is supported as medically necessary for treatment of this patients hepatitis C virus infection genotype 3a. 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 for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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. For documented reasons, the RTC level of care services were medically necessary for treatment of this patient.  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 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: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the requested services in this patients case.  The clinical notes document a body mass index of greater than 45.  However, current guidelines recommend documentation of failed dietary efforts as well as completion of a thorough multidisciplinary evaluation in order to establish that the patient is an appropriate candidate for bariatric surgery.  The documentation submitted for review does not include this information.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested bariatric surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 24 weeks 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions.  Per the guidelines, cirrhotic genotype 1a patients who have failed treatment with Sovaldi and ribavirin should be retreated with Harvoni and ribavirin for 24 weeks. However, studies have shown efficacy without ribavirin.  For these reasons, the requested treatment with Harvoni for 24 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: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee requested authorization and coverage of oral surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees malocclusion.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of the medication Protopic. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees onychodystrophy.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: Overturned

The parent of a 10-year-old female enrollee has requested Vyvanse 20 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that Vyvanse is the only ADHD medication that includes data on abuse liability. The fact that extensive data is available for Vyvanse and other longer acting medication makes this group of medication a first-line in the treatment of ADHD. Additionally, the patients need to maintain effect for most of the waking hours would make the medication medically necessary. Therefore, the request for authorization and coverage for Vyvanse for this young patient with ADHD has been established to be medically necessary and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3a. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines do not recommend NS5A resistance testing before use of Epclusa. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed at this time, and the requested treatment with Epclusa 400-100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The physician 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 physician 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 his 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.  For these reasons, the requested treatment with Harvoni 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

The parent of a two-year, nine-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that there is robust medical literature that supports the medical necessity of the requested speech therapy. As noted by Law and colleagues, children with speech delay can be successfully treated, as confirmed in this meta-analysis of multiple medical journal articles. Further, one prospective study from Pennington and colleagues commented on the accuracy of speech testing in a two-year-old population. The authors evaluated patients who were diagnosed with speech delays when they tested below the 10th percentile in expressive language. The authors concluded that these patients were correctly diagnosed, which prompted treatment with speech therapy resulting in marked improvement. Given the support for the efficacy of speech therapy in young patients with delayed expressive language skills, it is medically necessary that she receive speech therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewers found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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 ribasphere for 12 weeks for treatment of her hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the 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.  Urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis.  Early initiation of treatment may help patients avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.   All told, the requested Sovaldi and ribasphere for 12 weeks are medically indicated for the treatment of this patient. Final Result: Three reviewers 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 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.