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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin 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 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage. AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Sovaldi and ribavirin 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: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested the Oncotype DX tumor assay for an evaluation of her breast cancer. Findings:  The physician reviewer found that the greatest utility of the Oncotype DX is in determining whether an individual patient falls into the low risk category, for which hormone therapy alone may be sufficient, or the high-risk category, for which chemotherapy followed by hormone therapy is probably indicated. There is not unanimity of opinion among medical experts on whether the Oncotype DX assay should be routinely applied. The NCCN is split in their opinion about Oncotype testing. ASCO has approved the use of the Oncotype assay in early-stage breast cancer patients for decisions regarding chemotherapy. The TAILORX trial is a large cooperative group trial, currently investigating the benefit of chemotherapy in patients with an intermediate recurrence score with the Oncotype DX assay. Subjects with high and low recurrence scores were not randomized. This trial demonstrates the validity of the Oncotype DX tumor assay and the applicability of the results in patients with low recurrence and high recurrence scores, which constitutes approximately 70% of all results.
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 insufficient data to suggest treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers noted, There were no significant differences in rates of other morbidities or additional therapies between intensity-modulated radiation therapy (IMRT) and proton therapy. Per the researchers, among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity. Researchers found no significant difference in toxicity in patients with prostate cancer treated with IMRT and proton radiotherapy after one year. In this case, a photon-based treatment plan would not be contraindicated for a patient with hydronephrosis, and as the standard of care would be associated with a high level of safety and efficacy. Therefore, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy. Findings:  Two of the three physician reviewers found that guidelines now endorse the use of intraoperative radiation therapy in the treatment of breast cancer. The patient meets the criteria for the use of intraoperative radiation for the treatment of breast cancer. Studies have shown intraoperative radiation therapy is equivalent to standard external beam radiation therapy, but is associated with less treatment visits, making it easier for the patient. Therefore, intraoperative radiation therapy is likely to be of greater benefit than other treatment options. 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 reviewers 1, 2 and 3 are board certified in radiation 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 Orthovisc injections to the knee. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting. Evidence from studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The reviewer found that the current highest level suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Reviewer found the use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections for the knee are medically necessary to treat the patients medical condition at this time.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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male 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 the treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee has requested for Lap Band surgery for treatment of his obesity. Findings:  The physician reviewer found that there is a lack of scientific evidence indicating that pre-operative weight loss improves or predicts outcome. The requirement of participation in a six-month physician-supervised weight management program is not medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male 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: Experimental/Investigational
Decision: Upheld

The enrollees parent requested reimbursement for the Tryptase blood test. The enrollee has a food allergy to corn and corn derivatives. He underwent a tryptase blood test. The tryptase test, fluorescent immunoassay, measures both the alpha and beta forms of tryptase; measuring both forms increases sensitivity for the diagnosis of mastocytosis, and mast cell degranulation as a cause of anaphylaxis. Tryptase is ordered to evaluate acute anaphylaxis and mast cell disorders. This was not the case in this enrollee. This enrollee was not a good candidate for the tryptase blood test. Medical records did not support acute anaphylaxis or mast cell disease activation.Final Result: Three of the three reviewers determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the breast for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  MRI of the breast has specific indications as outlined by the American College of Radiology.  The most common indications for breast MRI is for high-risk women or for evaluation of a newly diagnosed cancer to rule out multifocal or multicentric disease.  MRI is a very sensitive exam in the diagnosis of breast cancer, but has a low specificity.  It is rare to diagnose a breast cancer in the setting of a negative clinical exam, negative mammography, and negative sonography.  Based on risk factors, this patient does not meet the requirements for MRI screening.  All told, the requested MRI of the breast is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are 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 diagnostic radiology 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 authorization and coverage for Mavyret 100-40 mg for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that The physician reviewer found 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Mavyret 100-40 mg is medically necessary 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

The parent of a six-year-old female enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that currently, the standard of care for young patients with autism includes a variety of services including speech therapy. The available scientific research shows that speech therapy improves patients with autism in their ability to communicate and interact with their environment. With regard to this patient, speech therapy has been focused on pragmatic skills that are necessary in a wide array of settings. Thus, these skills will enable the patient to interact with her community and establish her needs and desires. While the patient has showed progress with previous speech therapy, she continues to present with some deficits and therefore additional therapy is medically appropriate and indicated. For these reasons, the requested past and future speech therapy services have been established as medically necessary for management of this patients 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:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) statement of breast tomosynthesis states that tomosynthesis should no longer be considered investigational as it is a valuable tool in breast imaging. While there is a lack of long term studies proving an increased survival rate when tomosynthesis is used as part of a screening mammogram the addition of the technique has been embraced by providers due to an associated decrease in callbacks and an increase in detection of small cancers due to the tomographic quality of the technique which permits providers to separate dense glandular tissue from underlying architectural distortion.  Such distortion is often an indication of invasive ductal cancer.  The technique has proven to be especially valuable in patients with dense or heterogeneously dense breast tissue. Thus, the addition of tomosynthesis was likely more beneficial to this patient than two-dimensional digital mammography alone.   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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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 in 2014 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 performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology 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 mother of a 14-year-old female enrollee requested authorization and coverage of speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 41-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 I have determined that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested a home sleep study for the treatment of her sleep apnea. Findings:  Two physician reviewers found that the American Academy of Sleep Medicine published criteria and recommended portable devices type II, III, and IV for sleep monitoring to diagnose sleep apnea. Additionally, Centers for Medicaid and Medicare (CMS) supports coverage of type I through IV portable sleep monitoring devices. While there is evidence to suggest that portable monitoring can effectively diagnose sleep apnea in some cases, it may not be as accurate as polysomnography in certain patients, especially those who have mild apnea. Furthermore, the question at issue in this appeal is whether the proposed home sleep study is likely to be more beneficial than any standard therapy (e.g., an attended level one polysomnography). Review of the peer-reviewed scientific literature does not demonstrate that superior results are achieved with a home study as compared to an attended polysomnography. In fact, re-evaluation via polysomnography is needed if the results of the home study are negative.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi for 24 weeks for treatment of his chronic hepatitis C virus genotype 3a.  Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines state that immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. The AASLD/IDSA guidelines also endorse daily Sovaldi and weight-based ribavirin for 24 weeks as an alternative regimen for treatment naive patients with hepatitis C virus genotype 3 infection who are interferon ineligible. Thus, the requested Sovaldi for 24 weeks is medically necessary for treatment of this patients medical condition. 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.