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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica tablets for treatment of the enrollees chronic migraine headaches. Findings: The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. Lyrica (pregabalin) has the same mechanism of action as gabapentin, and neither has been demonstrated to have efficacy in reducing migrainous headache activity preventatively. There are small, open-label or non-randomized placebo controlled studies demonstrating possible benefit. However, the largest meta-analysis by Linde and colleagues concluded that neither has efficacy. Accordingly, Lyrica is not medically indicated and is not likely to be more effective than alternatives available. Therefore, Lyrica 100 mg tablets are not medically necessary for the treatment of this patient. 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 neurology 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 Viekira Pak or Harvoni for treatment of his hepatitis C virus (HCV).  Findings: Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, patients with chronic active hepatitis C are eligible for treatment and should be treated with FDA approved antiviral therapy regardless of fibrosis score. Moreover, 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. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Treatment with Harvoni improves patient-related outcomes across a range of domains, included health-related quality of life, vitality, fatigue, and work productivity. Moreover, treatment with Viekira Pak has been associated with high rates of SVR among previously untreated patients with HCV genotype 1 infection . Thus, the request for Harvoni or Viekira Pak is medically necessary for treatment of this patients medical condition. Final Result: Two 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. 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for dental general anesthesia. Findings:  The physician reviewer found that General anesthesia for pediatric dental procedures is generally 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. Typically, the combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for some pediatric patients. Upon review of the medical record, there is clear documentation of the need for extensive dental work for this patient. However, there is a lack of support in the documentation to suggest this patient meets criteria for the requested services. There is no record to show that this patient has a fear of needles and/or severe dental anxiety. In addition, there is no documentation of previous failed attempts to receive dental care with other dentists. Moreover, there is no indication that this patient has a significant cognitive impairment or is unable to cooperate and/or tolerate dental treatment in an office setting. There is no documentation to indicate that the use of local anesthesia and/or use of conscious sedation to control pain were not feasible based on the medical needs of this patient. For these reasons, dental general anesthesia is not medically necessary in this case.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 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 62-year-old female enrollee has requested for selective internal radiation therapy/intra-arterial Yttrium-90 therapy for treatment of her ovarian cancer with liver metastases.  Findings:  Two physician reviewers found that SIRT is useful for primary liver tumors as well as metastatic disease from the GI tract, this case does not meet those criteria. However, is that this patient has exhausted all systemic treatment and SIRT is essentially the only remaining option for palliation. The growth in metastases has been substantial over the last two months and thus palliative treatment appears reasonable. Although it is not considered to be a cure, SIRT has been shown to result in improved quality of life in terms of prolonged survival. Available data shows that there is relatively low toxicity and good response with SIRT, irrespective of tumor origin.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees ptotic eyelid tissue.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 53-year-old male enrollee has requested authorization and coverage for intravenous immunoglobulin therapy (IVIG) 1.4 g/kg for five days followed by a single dose every two weeks for treatment of the enrollee who has been diagnosed with autoimmune encephalitis and epilepsy.  Findings:  The physician reviewer found that The submitted documentation as well as the medical literature support the medical necessity of the requested services in this clinical setting. Rasmussens encephalitis is a rare neurological condition.  It is characterized as a chronic, progressive, focal (typically unilateral), and drug resistant with cognitive deterioration.  It is suspected that this disease entity is immune mediated. Typically, it is a disease that affects the pediatric population. However, adult cases have also been identified (10% of cases).  In the older population, the clinical course is usually slower and seizures semiology can correlate with temporal lobe dysfunction. A large proportion of the patient with Rasmussens encephalitis have epilepsia partialis continua.  Depending on the affected area, different focal semiologies may present themselves.  Patients who do not receive or respond to treatment can have significant morbidity with sequelae including but not limited to hemiparesis, hemianopia, cognitive decline, and dysphagia. According to the documentation, the patient has medically refractory epilepsy, focal damage and atrophy, cognitive loss, and identified episode of EPC correlating with the diagnosis of Rasmussens encephalitis. With Rasmussen's encephalitis the treatment paradigm includes treating the seizures as well as treatment against the underlying inflammatory process.  The patient is currently on a significant anti-epileptic regimen and with the addition of Onfi seems to have stabilized.  The proposed treatment for the underlying process is IVIG. Due to the rare nature of the disease, long term immunotherapy in Rasmussens encephalitis  is typically found in case reports or small uncontrolled patient series.  However, findings from these publications typically show good results with IVIG.  The available evidence supports a treatment approach that addresses the clinical manifestations of seizures as well as immune therapy against the disease process.  In the data, IVIG has been shown to be effective for treatment of Rasmussens encephalitis. For all these reasons, IVIG 1.4 g/kg for five days followed by a single dose every two weeks is medically necessary for treatment of this patients medical condition. 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 neurology 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

A 39-year-old female enrollee requested authorization and coverage of an osteochondral transplant. The Health Plan  denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees chondromalacia.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 37-year-old female who was diagnosed with medullary thyroid cancer (MTC) in August 2005. Her initial surgical procedures were total thyroidectomy, left neck dissection, limited right neck dissection, and parathyroid autotransplantation. The patient was noted to have a pulmonary metastasis that was also surgically removed. She then received radiation therapy. In June 2006 a PET scan demonstrated additional disease in the cervical and the iliac regions. The patient sought consultation where she was evaluated by a Head and Neck Oncology surgeon and a Medical Oncologist. Repeat imaging performed including MRI, CT and neck ultrasound which revealed multiple (5) cervical tumors. The patient has requested transfer of her care to MD Anderson Cancer Center for ongoing evaluation and treatment of her metastatic medullary thyroid cancer.  The Health Plan denied her request citing a lack of medical necessity.Following her diagnosis in August 2005, the patient has been treated surgically and with radiation therapy. She has documented recurrent disease in the cervical and iliac regions. The recommendation from the Head and Neck Oncology surgeon at MD Anderson was for continued observation taking into consideration the surgical risks and the potential indolence of this tumor. The Medical Oncologist essentially deferred to the Head and Neck Oncology surgeon regarding surgical necessity and recommended continued observation as a reasonable option if surgery was not needed. This recommendation was apparently based upon current the chemotherapys lack of efficacy, the potential for slow progression, and the hope for future availability of a clinical trial examining the efficacy of biologic therapy in sporadic MTC. Clinical trials are not open currently, but may at some point be available at sites across the United States.The current recommendation from MD Anderson is for continued observation and assessment of tumor growth.  There is no evidence to suggest that either imaging or treatment as currently recommended at MD Anderson would lead to a better outcome than the provision of those services by the Health Plan. Although an uncommon tumor, the options outlined by the consulting specialists at MD Anderson are available to the patient within her Health Plan. Therefore, I have determined the requested services are 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis.Pelvic MRIs are appropriate to assess for further pathology in the setting of insufficient prior imaging or if an alternative diagnosis is being investigated. In this case, the patient has had the gold standard imaging over the past few years to assess for any abnormalities in her pelvis. The patients imaging has shown adenomyosis and uterine fibroids. There is no clinical documentation stating that this imaging was insufficient. She has already been diagnosed with adenomyosis on prior imaging, so repeat MRI is not indicated for this diagnosis. Therefore, MRI of the pelvis is not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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

The enrollee requested Oncotype DX prostate testing for prostate cancer. The surgical pathology report showed adenocarcinoma, Gleason score 6. Per the genomic prostate score (GPS) report, the patients GPS score was 8, indicating very low risk, and his prostate specific antigen (PSA) level was 8.3 ng/mL. Per documentation, the patients physician ordered the test to identify the specific risk of aggressive prostate cancer. The physician indicates this information allows for a more informed decision between active surveillance and immediate intervention. The Oncotype DX Prostate Cancer Assay may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer. However, studies regarding the efficacy of this testing are recently published and need continued validation from widespread clinical use. In addition, it is difficult to ascribe clinical utility of Oncotype DX prostate testing in patients planning to undergo active surveillance as all patients in the studies, regardless of clinical criteria, elected radical prostatectomy within six months of diagnostic biopsy. Moreover, the validity of using different degrees of tumor pathology as markers to estimate the risk of progression of a tumor in the body is unclear. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology 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 authorization and coverage for Epclusa (sofosbuvir-velpatasvir 400-100 mg), 28 tablets for 28 days for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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 computer-assisted navigation during right hip replacement. Findings:  The physician reviewer found that Jacofsky and Allen report that while early results on the use of robotic-assisted orthopedic surgery as applied to total hip arthroplasty have demonstrated improved accuracy of placement, improved satisfaction, and reduced complications, further studies are needed. Wasterlain and colleagues note that the primary benefits of navigation are a reduction in outliers during acetabular cup positioning and improved accuracy when quantifying limp-length and offset measurements. However, it remains to be seen whether these benefits translate into meaningful improvements in clinical outcomes. Montgomery and colleagues report that data failed to demonstrate any clinically significant reduction in short-term adverse events with computer-assisted surgery applied to total hip arthroplasty and that further study was warranted. In this case, there is a lack of evidence that the use of computer-assisted navigation would have improved patient outcomes over standard arthroplasty without navigation. Therefore, computer-assisted navigation (CPT 0054T) during right hip replacement was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the computer-assisted navigation (CPT 0054T) during right hip replacement at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that service at issue was not 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 upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Gene Expression Assay. Findings:  The physician reviewers found that the current medical evidence does not support the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines states 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. In sum, DecisionDx-Melanoma Gene Expression Assay was not likely to have been of greater benefit than other available methods of evaluating this patient. Final Result: The reviewers determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in 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: Upheld

A 59-year-old female enrollee has requested Protonix 40 mg twice daily for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that pharmacologic therapy for GERD continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression and provide excellent relief of symptoms, and the healing of erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Although inter-patient variability of the efficacy has been seen, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles. The Health Plans formulary alternatives have similar efficacy and side effect profiles to Protonix. Therefore, the Health Plans recommendation of a trial with the preferred PPIs including omeprazole, Prevacid and Nexium is medically appropriate.