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

A 39-year-old female enrollee has requested chemotherapy with carboplatin and gemcitabine for treatment of her triple-negative breast cancer.  Findings:  Two physician reviewers found that triple-negative breast cancer (TNBR) is a newly defined subcategory of breast cancer which is especially responsive to platinum-based chemotherapy. Laessig and colleagues concluded that, Combination chemotherapy with gemcitabine and carboplatin is an effective and generally well-tolerated treatment option for intensively pretreated patients with metastatic breast cancer. In this young patient with no significant response to neoadjuvant chemotherapy, it would be medically reasonable to treat her with a platinum based chemotherapy combination of carboplatin and gemcitabine based on the relevant peer reviewed clinical literature demonstrating its efficacy and safety in this subset of patients. According to the scientific data, this systemic chemotherapy regimen is more likely to provide her with a superior health outcome than any standard treatment and should not be categorized as investigational in this setting
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested behavior modification therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that the medical literature confirms the success of ABA, both after several years of therapy and after long-term follow-up. In this instance, therapy is being supervised by qualified and licensed psychologists and social workers. The utilization of trainees in the medical arts has a long tradition of encouraging and depending on unlicensed personnel. Medical students and interns are supervised, but practice unlicensed medicine. Post-graduate psychologists and family therapists all need to spend three years of supervised clinical practice to be able to sit for the licensing examination. Thus, supervised therapy by a licensed therapist is licensed therapy by proxy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entresto. Entresto has been shown to be helpful in patients with Congestive Heart Failure despite treatment with optimal medical therapy. Based on the records, this patient has cardiomyopathy with reduced ejection fraction but no current heart failure symptoms or physical examination findings of congestive heart failure (CHF). Without evidence of CHF, the patient does not have an indication for Entresto. Entresto tablets are not medically necessary for 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 internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard IVIG home infusion services. The records provided for review document that this patients work-up has included abnormal skin biopsy results with reduced epidermal nerve fiber density and a high titer of TS-HDS antibodies. The patient has been treated with gabapentin with partial improvement. The patients provider has recommended treatment with IVIG with home infusion services. The treatment of patients with SFPN is dependent on the underlying etiology, including associations with systemic autoimmune conditions. IVIG is considered a first-line treatment for patients with immune-mediated neuropathies. Liu and colleagues reported evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. In this case, the patient has SFPN with a positive TS-HDS antibody titer. Based on the support in the current peer-reviewed medical literature, patients with autoimmune SFPN may show clinical improvement with IVIG. Moreover, the medical records support an indication for home infusion services for administration of the Gammagard IVIG for this patient. A recent study by Perreault and colleagues concluded that transition from clinic based to home based IVIG infusion can be successfully done to decrease potential exposure during a pandemic in a high-risk immunosuppressed population, with no impact on patient satisfaction, adherence, or efficacy. For these reasons, the requested Gammagard IVIG home infusion services are medically necessary for treatment of this patient.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested rabeprazole for treatment of her medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as to manage symptomatic gastroesophageal reflux disease and acid hypersecretory states.  Duration of action, side effects, and cost characterize proton pump inhibitor variations. No particular proton pump inhibitor can claim overall superiority, such that as a class proton pump inhibitors are interchangeable.  In this case, the available records do not support that the patients gastroesophageal reflux disease has advanced to Barretts esophagus, nor has she documented intolerance to specific proton pump inhibitors.  The available records do not indicate that she maximized treatment with step therapy.  All told, the requested medication rabeprazole is not medically indicated 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 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 patient is a 71-year-old woman who has eye irritation and pain in her left eye. She underwent bilateral cataract surgery in 1997. She has requested authorization and coverage for eye surgery. The Health Plan has determined the requested surgery is not medically necessary.The Health Plans denial should be upheld. There is no medical indication for eye surgery in this patient. The submitted records indicate the patient has been examined by several providers. None of the patients providers have recommended eye surgery. There is no evidence the patients eye irritation will be relieved by surgery. Thus, there is no medical justification for surgical intervention. Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested surgery for treatment of her unruptured left-sided aneurysm.  Findings:  The physician reviewer found that the cited article in the New England Journal of Medicine described a retrospective/prospective study of the natural history of unruptured cerebral aneurysms and the risks of repairing them. A total of 2621 patients at 53 participating centers were studied. In the retrospective component of the study, the authors assessed the natural history of unruptured intracranial aneurysms in 1449 patients.  Of these 1449 patients, 727 had no history of subarachnoid hemorrhage from a different aneurysm and were designated group 1 patients. In the prospective component, the treatment-related morbidity and mortality in 1172 patients with newly diagnosed unruptured intracranial aneurysms was assessed. In group 1 patients, the cumulative rate of rupture of aneurysms that were less than 10 mm in diameter at diagnosis was less than 0.05 percent per year. The overall rate of surgery-related morbidity and mortality for group 1 patients was 17.5 percent at 30 days and 15.7 percent at 1 year. The authors concluded that the likelihood of rupture of unruptured intracranial aneurysms that were less than 10 mm in diameter was exceedingly low among patients in group 1. Furthermore, the risk of morbidity and mortality related to surgery greatly exceeded the 7.5-year risk of rupture among patients with unruptured intracranial aneurysms smaller than 10 mm in diameter.  The patient in question would be considered a group 1 patient and would be better cared for by observation of her aneurysm rather than surgical repair.  All told, the requested surgery is not medically indicated for the treatment of this patients unruptured left-sided aneurysm.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent guidelines all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high-quality 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. The guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment for Viekira Pak 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. As ultrasound elastography showed a lack of cirrhosis, thus this patient should be treated as a non-cirrhotic patient.  The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret. These 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 ENDURANCE-1 trial showed that only eight weeks of treatment is needed. The patient has an isolated positive core antibody, with negative surface antigen and antibody, most consistent with resolved infection, or less likely a false-positive anti-core antibody. In this case, the patient had no detectable hepatitis B viral load, and does not have an active infection. Even if the patient had active hepatitis B, the AASLD/IDSA guidelines state that [Hepatitis B surface antigen] HBsAg positivity does not represent a contraindication to HCV [direct acting antivirals] DAA therapy. Guidelines further that There are insufficient data to provide clear recommendations for the monitoring of hepatitis B DNA among patients testing positive either for anti-HBc alone (isolated anti-HBc) or for anti-HBs and anti-HBc (immune recovery). Therefore, there is no hepatitis B-related contraindication to starting Mavyret therapy in this case. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of the patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old male enrollee requested authorization and coverage of a GlucoWatch. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees diabetes mellitus type I.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three CHDR physician reviewers concluded that the requested therapy 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

The patient is a 24-year-old female with a body mass index (BMI) of 67.8. The patient also indicates she has a number of comorbid conditions.  She has requested authorization for Lap-Band surgery. The Health Plan has denied this request on the basis that Lap-Band surgery is not medically necessary for treatment of the patients medical condition. Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for facial feminization surgery and a tracheal shave.The patient has submitted multiple documents that support her claim that the requested surgeries are a medical necessity. A letter from the patients therapist states that the requested facial feminization surgeries and tracheal shave will serve to decrease the patients felt emotional effects of gender dysphoria. The patients primary care provider also supports the medical necessity of the requested surgeries to treat the patients gender dysphoria. Under these circumstances, the requested facial feminization surgeries and a tracheal shave are medically necessary to treat the patients gender dysphoria.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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HopeSeq Solid Tumors Comprehensive next generation sequencing (NGS) panel. Findings:  The physician reviewer found that This patient presents with carcinoma of unknown primary. The pathologic description was suggestive but not completely diagnostic. Molecular profiling based on gene expression or comprehensive mutational analyses has proven to be highly accurate in determining the tissue of origin, which will enable decision-making regarding appropriate therapies (Conway, et al.). In some small phase II studies, patients with carcinoma of unknown primary treated with medications selected based on their tissue of origin demonstrated better responses than patients who were treated empirically (Hainsworth, et al.). Moreover, there is evidence in the medical literature that mutational profiles can help aid diagnosis and guide therapy (Palma, et al.). The NCCN guidelines state that, Consider NGS in patients based on clinicopathologic features and where it guides therapeutic decision-making. The HopeSeq solid tumor panel is a NGS test for multiple mutations in cancer-causing genes in diverse solid tumors. All told, requested HopeSeq Solid Tumors Comprehensive NGS panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested services are likely to be more beneficial for evaluation 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 evaluation 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certifications in hematology and internal medicine 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested exploratory laparotomy and tumor cytoreduction for treatment of the enrollees neurofibromatosis type 1 with metastatic gastrointestinal stromal tumor.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has an aggressive drug resistant tumor.  Surgery would be beneficial if a complete resection with no microscopic residual tumor or complete resection with no grossly visible tumor could be achieved.  The likelihood of that given her two prior operations and rapid progression makes this unlikely.  Surgery for advanced disease in the setting of drug resistance is also of unknown benefit.  The records indicate that the patient has been managed in a complete, multidisciplinary format.  The provider who previously performed the cytoreduction did not believe that complete resection was feasible or that the associated morbidity was in her best interest.  There is a lack of support for the requested services in this clinical setting.  All told, the requested exploratory laparotomy and tumor cytoreduction is not medically indicated 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for positron emission tomography with concurrent acquired computed tomography for attenuation correction (PET/CT) scan. The requested PET/CT scan is not indicated for surveillance or diagnosis of colon cancer. The National Comprehensive Cancer Network (NCCN) guidelines discourage the routine use of PET/CT scanning for staging, baseline imaging, or routine follow-up. PET/CT scans performed without contrast and multiple slicing do not obviate the need for a contrast-enhanced diagnostic CT scan to work-up colon cancer. A CT scan would be preferred at baseline to look for a suspicious malignancy. This patients initial diagnosis was 10 years ago and he has a normal carcinoembryonic antigen (CEA). These factors do not support an indication for a PET/CT to evaluate for possible recurrence. Given these findings, the requested PET/CT scan is not medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 43-year-old female enrollee requested authorization and coverage of a total abdominal hysterectomy with bilateral salpingo-oophorectomy and bladder suspension. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees menorrhagia.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.