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

The parent of a 2-year-11-month-old female enrollee has requested  for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the common practice of the medical community is to refer a speech-delayed child to a speech therapist to develop speech. There is a robust medical literature supporting speech therapy in this population. Children with speech delay can be readily treated (Law, et al.) and cognitively normal children are ideal candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). Speech therapy has been found to be efficacious in the treatment of speech delays in young children (Emmanuel, et al.). Thus, it is medically necessary for this patient to receive individual speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage of a referral to a neurologist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for evaluation of the enrollees arm pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression. Findings:  Three physician reviewers found that TMS therapy remains an unproven modality of treatment for any neuropsychiatric disorder, including depression. A 2002 Cochrane Review concluded that in 16 published trials there was no strong evidence of benefit from using TMS for the treatment of depression. One major conclusion of this report was the finding that there was no difference between TMS patients and sham TMS patients, based on results of the Beck Depression Inventory or Hamilton Depression Rating Scale. Further research is needed to support the use of TMS in terms of outcomes and long-term efficacy when used in the treatment of depression and other psychiatric disorders. Moreover, little is known about the long-term effects of this therapy. Seizures have been reported after repetitive TMS.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care provided during a colonoscopy. According to the American Society of Anesthesiologists (ASA) guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care may be considered for prolonged or painful procedures. These may include procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. The guidelines further note that monitored anesthesia care may be considered for patients with previously anticipated intolerance to standard sedatives, psychological impediments to cooperation, ASA class of IV or V, or who are at risk for airway obstruction due to anatomic variant. Monitored care anesthesia may also be used for prolonged procedures requiring deep sedation. According to American Society for Gastrointestinal Endoscopy (ASGE) practice guidelines, consciousness during endoscopic procedures, unlike in surgery, is acceptable and is the goal during most procedures. In this case, despite being requested, the submitted records did not document that the patient met these criteria or other criteria found in current medical literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater 70 years, pregnancy, increased aspiration risk, ASA class three or higher, or morbid obesity. Therefore, monitored anesthesia care provided during a colonoscopy was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 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: A enrollee has requested reimbursement for gene panel testing. Per the American College of Obstetricians and Gynecologists (ACOG), expanded carrier screening does not replace previous risk-based screening recommendations. All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis and spinal muscular atrophy . However, expanded carrier screening panel testing using next generation sequencing technology is not currently considered within the standard of care. There is a paucity of evidence in the peer-reviewed literature from large, randomized trials or high-quality prospective observational trials supporting the clinical utility and impact on patient management of expanded carrier screening panels using next generation sequencing. Moreover, these panels have significant limitations, including increased false positives and variants of unknown significance. Specific screening may be indicated based on a patients family history or specific ethnicity. However, this patients records do not include clinical documentation of any family history or ethnic risk factors. For these reasons, the gene panel testing was likely to be more beneficial for evaluation of this patients medical condition than available standard therapy, while others were not likely to be more beneficial for evaluation of this patients medical condition than available standard therapy.One reviewer found that the gene panel testing was not likely to be more beneficial for evaluation of this patients medical condition than available standard therapy.Final Result: Two of the three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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

A 57-year-old female enrollee has requested interferential therapy for the treatment of her thoracic outlet syndrome, degenerative cervical disc disease and fibromyalgia. Findings:  Three physician reviewers found that interferential therapy to reduce pain from all causes is experimental at this time. Its effectiveness has not been demonstrated in the peer-reviewed literature. Studies showing health outcomes with interferential therapy over conventional therapy do not exist. The treatment remains experimental for chronic pain due to fibromyalgia, cervical degenerative disk disease and thoracic outlet syndrome. Its use in this case is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested electron beam computerized tomography (EBCT) coronary artery calcium (CAC) scoring for an evaluation of his coronary arteries. Findings:  Three physician reviewers found that EBCT for CAC scoring is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset. It is not a medically acceptable replacement for conventional screening tests within the standard of care such as treadmill stress testing.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BRCA gene testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the submitted documentation does not support the requested services in this clinical setting.  BRCA gene testing is premature in this patient. There is no mention of siblings or ethnicity, both of which may impact the pre-test probability of this patient being a BRCA carrier.  Thus, the requested BRCA gene testing is not likely to be more effective than other modalities for evaluating this patient. Final Result: Two reviewers determined that the requested services are 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 medical oncology 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 Guardant360 test.  Findings:  Two of the three physician reviewers found non-small cell lung cancer, particularly adenocarcinoma, should be tested for specific mutations. Although tissue diagnosis is proven to be the most reliable, blood DNA analysis is considered a reasonable alternative in situations where tissue biopsy is not feasible. Guardant360 assay is a blood-based assay of a large array of mutations. In this particular case, where the initial diagnostic biopsy was not sufficient for mutation analysis, it would be reasonable to evaluate for these mutations in the blood rather than expose this patient to further needle biopsy. In sum, Guardant360 test 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 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 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 30-year-old female enrollee requested authorization and coverage of the medication Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees onychomycosis.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing. Findings:  Three physician reviewers found that the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization is not yet ready for mainstream clinical application as the relatively small, short-term studies to date have not been replicated on a larger scale.  According to the American Psychiatric Association (APA), Current evidence provides limited support for the utility of pharmacogenetic testing, while trusted psychiatric reference texts do not recommend genetic testing for cases involving routine medication management. Additionally, there was no clinical data provided to support genetic testing.  The documentation did not include the patients longitudinal illness burden and extent of impairment, psychosocial stressors and medical comorbidities, if any. Further, there was no psychiatric assessment, interpretative summary, clinical formulation or treatment history. As such, it cannot be inferred that the patient had exhausted standard treatments available to treat his anxiety and schizoaffective disorders. In sum, genotype testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three Physician reviewers are board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that based upon 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. 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. For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for 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 39-year-old male enrollee has requested for Botox injections for treatment of his migraine headaches.  Findings:  The physician reviewer found that the literature regarding Botox shows it to be well tolerated, generally without systemic side-effects, and with adverse effects that are generally mild to moderate in severity. The most recent and largest studies show the benefit of Botox use in patients with migraine headache.
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 guidelines issued, 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 medical guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. 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. The guidelines also cite data showing increased survival with earlier treatment. 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: Medical Necessity
Decision: Upheld

The parent of a 4-year-old male enrollee has requested for 30 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted clinical information does not establish the need for 30 hours per week of ABA therapy. Based on the patients documented deficits and current level of functioning, the Easter Seals plan for 15 hours of ABA per week is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of metal-on-metal hip surface arthroplasty. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees osteoarthritis.Three physician reviewers performed a medical necessity 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 treatment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.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: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for 12 weeks for treatment of the enrollees 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 (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 1b patients should be treated with regimens including Zepatier for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Zepatier 50/100 mg for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 reimbursement for BRCA genetic testing.Findings:  Three of three physician reviewers found that National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology support the use of BRCA 1 and BRCA 2 gene testing in this clinical setting. According to the National Comprehensive Cancer Network (NCCN) guidelines on BRCA screening for breast cancer, BRCA 1/2 screening is warranted in individuals with a personal history of breast cancer who have two or more close relatives who have also been diagnosed with breast cancer (at any age). After risk assessment and counseling has been performed, BRCA 1/2 testing is then recommended. The patient in this case has met this NCCN criteria. Up to 10% of breast cancers are due to specific mutations in single genes that are passed down in a family. Specific patterns of hereditary breast/ovarian cancers are linked to mutations in the BRCA 1/2 genes. Testing for BRCA 1/2 in this case is thus both evidence based and a best practice. Accordingly, BRCA genetic testing provided on 8/19/19 was likely to have been more beneficial than any other available standard testing for the patients medical condition.Final Result: Three of three reviewers determined that the services at issue were likely to be more beneficial than any other available standard testing for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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.