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

Nature of Statutory Criteria/Case Summary:  An enrollee requested percutaneous tibial nerve stimulation for treatment of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the requested services in this clinical setting.  Percutaneous tibial nerve stimulation is considered a standard third-line treatment option for overactive bladder per current guidelines.  In this case, the records provided do not indicate that the patient has failed first-line and second-line treatment options for overactive bladder. Therefore, the requested percutaneous tibial nerve stimulation is not likely to be superior over other treatment modalities.Final Result: Three reviewers determined that the 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: Reviewers 1, 2, and 3 are board certified in urology 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 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

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 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 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. AASLD guidelines cite data showing reduced survival with delayed treatment. 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injections. An exhaustive review of current medical literature pertaining to the viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective.  The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the options are limited, with the alternative being a total knee arthroplasty. As such, the requested Synvisc One injections are medically necessary for treatment of patients knee osteoarthritis.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery 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 laboratory testing for evaluation of his medical condition. Findings:  Three physician reviewers found that the use of Anser ADA testing has not been clinically proven to improve patient clinical outcomes. The effectiveness of Anser ADA compared with conventional courses of action remains unproven.  Patients who are treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management.  In sum, laboratory testing was not likely to have been superior over other methods of evaluation.  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:   All 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: Medical Necessity
Decision: Upheld

A 27-year-old male enrollee requested authorization and coverage of the medication Amevive. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier one tablet daily for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer has found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. 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 or 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 (Zeuzem, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The 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: 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: Upheld

A 23-year-old female enrollee has requested duodenal switch surgery for treatment of her obesity.  Findings:  The physician reviewer found that this patient has a BMI of 43 and is a potential candidate for any standard primary weight loss procedure including the laparoscopic gastric banding, laparoscopic Roux-en-Y gastric bypass, laparoscopic vertical sleeve gastrectomy, and duodenal switch. The National Institutes of Health (NIH) consensus guidelines indicate that psychological clearance must be obtained. The remainder of a multidisciplinary evaluation includes medical clearance, evidence of dietary efforts, and dietary clearance, which were not provided. Therefore, the medical necessity for the requested duodenal switch is not determined at this time for failure to document failed weight loss efforts, and completion of a thorough multidisciplinary evaluation without barriers to surgery.
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 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. The guidelines state that patients with diabetes mellitus are at high risk for fast progression of fibrosis. Per the guidelines, treatment-experienced genotype 1 patients should be treated with Harvoni for 12 weeks. This guideline recommendation is 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 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: 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 provides significant advantages due to its tomographic nature.  This modality allows providers to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis was likely of greater benefit to this patient than had the examination been done with two-dimensional technique alone.  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: 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.  The American Association for the Study of Liver Diseases and Infectious Diseases Society of America 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.  Initiation of treatment with early-stage disease may avoid untoward complications from advanced disease, including liver failure and extrahepatic manifestations of hepatitis C.  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: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested bariatric lap band surgery for the treatment of her obesity. Findings:  The physician reviewer found that a study by Sjostrom and colleagues demonstrated that the only viable option for resolving the co-morbidities of obese patients and to improve their long-term life expectancy is weight loss surgery. There is no benefit in postponing or delaying the surgical treatment of this patient until she achieves a BMI of 40 or other co-morbidities are diagnosed. The patient has high cholesterol which increases her risk of cardiovascular illnesses. As such, lap band surgery is medically appropriate for this patient and has a proven track record of long-term success.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. There is a lack of support for the requested services in this clinical setting. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers  performed a recent multi-institutional analysis of 1,850 patients with low-risk or intermediate-risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, the authors found no difference in disease control between the two modalities. The American Society of Radiation Oncology (ASTRO) noted, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. Therefore, the requested proton beam radiation therapy is not medically necessary 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 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: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested duodenal switch bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health guidelines for weight loss surgery. The published data support the position that the co-morbidities and the associated illnesses of the obesity have a much higher chance of resolution with the duodenal switch operation than the alternatives of Roux-en-Y gastric bypass, adjustable gastric banding or the sleeve gastrectomy. The relative improved outcome is in some cases more than double that of the alternative procedures being offered. Buchwald and colleagues summarized the outcomes of different types of surgical weight loss procedures based on excess weight loss and resolutions of co-morbid conditions. The duodenal switch procedure was determined to show the most improvements among bariatric procedure alternatives (including Roux-en-Y gastric bypass, gastroplasty and gastric banding). There was significant hyperlipidemia improvement, diabetes resolution and excess weight loss reported with the duodenal switch procedure more often than with any of the other procedures surveyed. While the peri-operative complication and mortality rate is lower with the lap-band and Roux-en-Y gastric bypass, there is no evidence that the duodenal switch procedure has an unacceptable safety profile. The duodenal switch procedure has a better relative expected outcome, and as long as the patient is properly informed of the associated risks, the duodenal switch operation is medically appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested reimbursement for FoundationOne CDx testing. All patients with metastatic colorectal cancer should undergo tumor genotyping for RAS (KRAS and NRAS) and BRAF gene mutations individually or as part of a next-generation sequencing panel. Parsons and colleagues note that colorectal cancer that demonstrates microsatellite instability (MSI) may be caused by germline mismatch repair (MMR) gene mutations. Universal MSI and/or MMR testing is recommended for all patients newly diagnosed with colon cancer, along with HER2 testing. As the results from these tests help determine both standard treatment recommendations and clinical trial recommendations, the service at issue was likely to have been more beneficial than any standard therapy. Therefore, FoundationOne CDx testing was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the FoundationOne CDx testing was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested reimbursement for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children needing mental health treatment. The patients score correlates with a treatment intensity level of care of Level Five, or Medically Monitored Residence Based Services. Consistent with CALOCUS, it is possible to provide Level Five services in a child or adolescents home, if wraparound planning and resources can provide the needed service intensity in the less restrictive environment. In this case, the wraparound services offered by the IOP met this level of care. Therefore, the intensive outpatient program (IOP) services at issue were medically necessary to treat the patients medical 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, with subspecialty certification in child and adolescent 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.