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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Assay. Findings:  Three physician reviewers found that there are three basic approaches to the treatment of localized prostate cancer. These approaches are surgical prostatectomy, radiation, or active surveillance. The latter approach involves careful follow-up, but no specific treatment for the cancer. Treatment recommendations are based on risk stratification, which is a method incorporating clinical and pathologic findings. A further refinement of prognostication is the use of gene panels, such as Oncotype DX Prostate Assay. This is a 17-gene panel that is increasingly used to guide initial treatment for localized prostate cancer. There is sufficient support for the services at issue in this clinical setting. Therefore, Oncotype DX Prostate Assay was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg 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 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C virus. 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. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks regardless of interferon eligibility. This is based on the ALLY-3 study, which showed a cure rate of 97%. The guidelines cite study data reporting that delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure for intraosseous basivertebral nerves. As noted in the peer-reviewed medical literature, the use of Intracept procedure has been shown to be safe, effective and durable in multiple randomized controlled trials with follow-up beyond five years. The Intracept procedure is a minimally invasive outpatient procedure that is implant-free and allows for fast recovery. The Intracept procedure also preserves spinal integrity by negating need for extensive tissue exposure and disruption. This patient presents with a three-year history of severe chronic low back pain. The records document that the patient has been treated with conservative therapy including physical therapy, lumbar epidural injections, and medication management without substantial relief of her symptoms. The patients ability to perform activities of daily living have been severely limited due to her condition. Currently, there are no signs or symptoms of radiculopathy or myelopathy. Based on radiographic and MRI findings, the patient is a candidate for treatment with the Intracept procedure. For these reasons, the requested Intracept procedure for intraosseous basivertebral nerves is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested Intracept procedure for intraosseous basivertebral nerves is 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 services are 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: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient hospitalization level of care services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Per the medical records, clinical services could not have reasonably been delivered in a less restrictive setting while outpatient treatment would have resulted in inadequate care.  Due to the acute psychiatric syndrome with concern of suicidality and behavioral dysregulation, psychiatric hospitalization was initially indicated.  The patient promptly engaged the services afforded by the inpatient setting, including the initiation of a novel antidepressant.  The services and setting were safe, appropriate and consistent with good medical practice.  Nursing documented a normal mental status examination with mild depression.  The patient was not psychotic, suicidal, confused, boisterous or threatening.  The psychiatrist indicated that the patient was depressed, anxious, isolative, and felt hopeless and helpless.  The patient had no suicidal ideation or cognitive impairment, and was deemed to have good impulse control.  The patient had another reassuring nursing report.  According to the records, the patient was tolerating his new medication and understood that it would take time to determine its suitability in his case.  His thought processing was goal-directed, and he had no suicidality.  Further, he was attending to his activities of daily living, which he had been neglecting prior to admission.  During the course of the admission, although mildly depressed, the patients acute psychiatric syndrome resolved, and he did not voice any new complaints or express any suicidal ideation, homicidal ideation or aggressive behavior.  Thus, inpatient hospitalization levels of care services were medically necessary, but not thereafter.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of botox injections for the treatment of migraine headaches.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that botox injections are not likely to be more beneficial for treatment of the enrollees migraine headaches than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for chromosomal microarray (CMA) FirstStep Dx Plus testing for evaluation the enrollees autism spectrum disorder. Findings:  Three physician reviewers found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for individuals with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), and the Child Neurology Society (CNS). CMA technology has been shown to provide clinically actionable information. In a study, a retrospective chart review of CMA testing was performed on individuals with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies in order to determine the proportion of cases where abnormal CMA results impacted recommendations for clinical action. Among the 1,792 patients that were reviewed, 13.1% had clinically relevant results, either abnormal or variants of possible significance (VPS). When an abnormal result was identified, a recommendation for clinical action was made 54% of the time. Findings in this study demonstrated that CMA results influenced medical care by in the majority of patients by, supporting the use of CMA as a clinically useful diagnostic test. Final Result: The reviewers determined that the requested testing 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: Reviewers 1, 2 and 3 are board certified in pediatrics and genetics 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

The parent of a 10-year-old female enrollee requested Concerta (methylphenidate 18mg extended release for medical treatment of the enrollees attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that stimulant medication is the gold standard pharmacologic intervention for attention deficit/hyperactivity disorder.  According to guidance from the American Academy of Child and Adolescent Psychiatry, long-acting formulations, such as Concerta, are first-line initial treatments.  They are efficacious and optimize adherence as they are single daily dosing medications.  In this case, the patient was previously treated with Concerta.  The submitted documentation noted that this medication was well-tolerated and effective for the treatment of this patient.  The medical evidence supports the requested medication in this clinical setting, given this patients prior response.  All told, Concerta (methylphenidate 18mg extended release) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested an electrical bone growth stimulator for treatment of his scaphoid nonunion.  Two physician reviewers found that in this patients case, the requested device is not likely to be more effective than other treatment options.  The patient has a history of wrist trauma while playing football, with current x-rays demonstrating scaphoid nonunion.  The current medical evidence does not support the requested device in this clinical setting.  There is a paucity of randomized, placebo-controlled studies supporting the use of electrical bone growth stimulation in nonunion of the scaphoid.  The patient underwent scaphoid nonunion repair with iliac crest bone graft.  The records noted observed bleeding from both sides of the nonunion site, and this increases the likely success of non-vascularized bone graft.  Therefore, the requested electrical bone growth stimulator is not likely to be superior over other options.  Final Result: Two reviewers determined that the requested device 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.  Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery 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

The mother of a 16-year-old female enrollee has requested for intravenous (IV) Rocephin for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the Lyme Western blots do not indicate active infection. Her symptoms are not specific for Lyme, and multiple courses of antibiotics have not improved her condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of her medical condition. Findings:  Three physician reviewers found that the current medical evidence does not support the requested services in this clinical setting.  Interventional pain procedures may be utilized for the treatment of severe musculoskeletal pain when conservative treatments with medications, exercise and physical therapy have failed.  In this case, the records showed subjective report of pain relief with objective measures of functional restoration following the diagnostic facet procedures.  However, the subjective, objective and magnetic resonance imaging (MRI) findings is consistent with radicular low back pain.  The records did not show that the patient has failed conservative treatment with NSAIDs, exercise, physical therapy and behavioral modification.  In sum, the requested services are not likely to be of greater benefit than other treatment options.  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: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested Norco 5-325 (one tablet twice per day) for treatment of his ulcerative colitis, and foot and knee pain.  Findings:  The physician reviewer found that the American Association of Orthopedic Surgeons (AAOS) has recommended against the routine use of opioids for the treatment of pain associated with osteoarthritis of the knee. Trials of NSAIDs, low impact exercises and weight loss for a body mass index (BMI) greater than 25 are all evidence-based recommendations which have not been documented in this patient. Similarly, the American College of Rheumatology (ACR) has recommended the use of opioids conditionally after documenting that the patient had an inadequate response to initial therapy. However, adequate trials of physical therapy and treatment with NSAIDs have not been documented in the records provided for review. Thus, the requested Norco 5-325 (one tablet twice per day) is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for psychiatric residential treatment center level of care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the services at issue. The patient was admitted due to oppositional behavior at home, failing at school, anxiety, and treatment for ADHD. During the dates of service in dispute, the patient did not have suicidal thoughts. The patient had no substance abuse history. Overall, this patient interacted well with staff and peers. The patient was engaged and participated in treatment. The patient had no history of aggression and did not exhibit aggressive behavior towards others. The patient was compliant with medication therapy. The patient continued to have some OCD symptoms with some increased anxiety, but was described as having an otherwise stable mood. The record indicates that this patient had improved enough to be discharged to a less restrictive environment. The patient did not have symptoms that require 24-hour supervision. The patient continued to require treatment for ADHD, OCD, and generalized anxiety disorder. However, the patient could have been treated in a less restrictive environment. Therefore, psychiatric residential treatment center level of care provided  were not medically necessary for the treatment this patient.Final Result: The reviewer determined that the services at issue were 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a diagnostic bilateral breast MRI for her breast cancer monitoring. Findings:  The physician reviewer found that breast MRI is a valuable tool used in addition to mammography and ultrasound. However, the clinical efficacy of breast MRI is limited to select patients. These include those with known breast cancer to evaluate for extent of disease, those patients with lymph node positive breast cancer and normal mammograms, and for screening high risk patients (i.e., those with BRCA mutation).  This patient has no personal history of breast cancer, her mothers breast cancer occurred post-menopause, and there is no history of BRCA mutation.  There is consequently no medical evidence to support breast MRI for screening purposes.  As this patient has had prophylactic mastectomies for non-cancerous breast disease, the chance of developing breast cancer is reduced because she no longer has breast tissue. Mammography would be appropriate for breast cancer screening in this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that residential treatment center services were not medically necessary for treatment of the patients medical condition. The patient was not a danger to herself or others, and was able to contract for no self-harm. She was medically and psychiatrically stable. Her body weight was stable. Her eating disorder behavior was somewhat unclear and not witnessed by staff or others. She was engaged in treatment. Although the patient required education and individual, group, and family therapies related to her eating disorder and some degree of supervision to ensure compliance with her meal plan, there is a lack of evidence demonstrating that any of these treatments could not have been safely provided at a lower level of care such as a partial hospitalization program. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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.