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

A 43-year-old female enrollee requested authorization and coverage of the prescription medication Meridia for the treatment of obesity.  The health plan denied the enrollees request indicating that the requested meridia is not medically necessary. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested prescription medication, Meridia, is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. Current medical literature supports the use of the requested procedure in leading to statistically significant improvement over continuation of standard treatment. Fischgrund and colleagues report that patients treated with radiofrequency ablation of the basivertebral nerve for the treatment of chronic back pain maintained benefits at two years following treatment in both Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). The primary finding correlating to success of the requested procedure is the presence of MRI changes showing edema in the vertebral bodies. In this case, an MRI demonstrated such findings. Therefore, the Intracept procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Intracept procedure 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 service is 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 orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement of Decision Dx-Melanoma Gene Assay for a diagnosis of malignant melanoma. He saw a surgical oncologist for a lesion on his right leg that performed a biopsy of the skin of the right medial leg. Findings:The pathology report showed it was positive for malignant melanoma. DecisionDx testing was ordered and the report showed Class 1, Sub-class: 1A, which is associated with a low risk of recurrence within five years.  According to the medical literature, the DecisionDx-Melanoma test is a 31-gene panel assay used to determine the risk of recurrence and metastases of the melanoma. However, there is no definitive data regarding its use for risk classification in cutaneous melanoma and the test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy either as standard of care or in clinical trials. Gene subsets differ from study to study and prospective clinical trials testing the utility of these techniques have yet to be reported.  The test does not provide any additional benefit or information compared to the standard of care procedures. The literature indicates definitive assessment of the sensitivity and specificity of this test should be conducted in patients who are representative of the general primary melanoma patient population.  Guidance on interpretation of the results is of critical importance.Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard testing for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in hematology and medical oncology; the second reviewer is board certified in surgical oncology; the third reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epoetin alfa (Procrit) 40,000 units per week. Findings:  The physician reviewers found that, although Procrit alone is not recommended for the use of sickle cell disease, the use of Procrit in combination with hydroxyurea may be considered as an adjunct to hydroxyurea therapy in patients with high risk sickle cell disease, anemia, low reticulocyte counts, and deteriorating renal function, particularly when hydroxyurea therapy is limited by the erythroid reserve. The National Institutes of Health (NIH) reported on the use of this combination based on an observational study and review of the literature. The NIH found that Procrit can help combat the side effects of higher hydroxyurea dosing. Thus, the use of Procrit 40,000 units per week in this patient is likely to be more beneficial than any other available standard therapy. Final Result: 2 of 3 reviewers determined that the requested medication is 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: All three physician reviewers 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  In this case, the patient has breasts that have been described as extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Similarly, with the questionable history of an axillary mass, a tomosynthesis is especially valuable considering the density of her breasts. For the reasons provided, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested autologous stem cell transplant for treatment of his Light Chain Deposition Disease (LCDD).  Findings:  Two physician reviewers found that in the treatment of LCDD, autologous stem cell transplantation with high-dose melphalan has been used in a small number of cases. The results are relatively favorable with about half of the patients showing improved renal function and a high percentage in hematologic remission (Lorenz, et al). However, studies have also reported toxicity of the transplant including mortality and relapses (Fujita, et al). On the basis of the existing literature, most experts do not consider autologous transplantation a first-line therapy, although it offers an alternative based on small series with some published success (Weichman, et al). Given the uncertainty of the efficacy and safety of autologous stem cell transplantation in patients with LCDD, its use is not indicated in this patient who has responded to a conventional therapy and has no current indication for a more aggressive treatment approach at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for testosterone gel. Findings: Male hypogonadism may present with multiple symptoms, including diminished libido and erectile dysfunction, fatigue, irritability, increased body fat, decreased muscle mass and osteoporosis. A study notes that testosterone treatment is indicated for men with symptomatic testosterone deficiency. Another study notes that there are several possible administration routes for testosterone treatment. The authors state, Although new developments are promising, it seems that among the available treatments, only transdermal gel delivery and long-acting injectable testosterone undecanoate provide pharmacokinetic behavior that gives a steady state level within a physiological range. Therefore, testosterone gel 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 endocrinology, diabetes and metabolism 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that review of the submitted evidence demonstrates the requested Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The providers recommendation of Harvoni is consistent with FDA guidelines and is medically indicated to prevent further development and progression of fibrosis due to ongoing HCV infection. All such, the requested Harvoni  is medically necessary for treatment of the patients hepatitis C virus. 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

A 60-year-old female enrollee requested authorization and coverage of Epogen injections. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees side effects of her hepatitis treatment.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female has requested weekly speech therapy for treatment of the enrollees expressive language delay.  Findings:  The physician reviewer found that language development in the internationally adopted child can be complex.  Some experts cite the significant and detrimental effect of premature arrest of the primary language when a child, who has often been neglected, is adopted and immersed into a new language culture.  This can ultimately slow the language development process in the new language.  Studies have demonstrated that most children 12 months of age or younger adopted internationally typically catch up quickly on language skills and vocabulary.  When they do not, speech and language services are recommended.  When children are brought to the United State later in life (ages one to three years), they catch up more slowly, but still achieve age-appropriate English language skills by approximately four years of age.  When this is not the case, experts recommend early intervention services. In this patients case, the last available speech and language report suggests that at four years two months of age, she was making three to four word utterances, with use of many incorrect pronouns.  Vocabulary was also limited.  This progress, while positive, is not consistent with the more typical trajectory of speech and language developmental in an internationally adopted Eastern European cohort, as studied by Glennen.  There is documentation that this patient also has global developmental delays.  Furthermore, she may have been alcohol exposed.  All told, in this patients case, the requested weekly speech therapy from the date in question forward was and is medically indicated.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services on an emergent or urgent basis.   The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention during the period in question. Upon review of the submitted medical records, the patient presented with a history of biopsy proven polymyositis. The medical records demonstrate normal visits and exam but slightly worsening CPK levels. Although there is some evidence of worsening on labs, her levels were not the tenfold increase typically seen with very active disease and ESR was normal. The records do not demonstrate weakness or difficulty breathing or other signs of acute distress. All told, there is a lack of evidence the patient was exhibiting signs and symptoms during the disputed period that would lead a prudent layperson to believe she was experiencing an emergency medical condition requiring immediate attention. Thus, the requested services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the dates in dispute. In this case, the records fail to document a serious worsening of the patients condition during the dates of service at issue. The patient sought treatment for a chronic condition and there is a lack of evidence she was experiencing complications of her existing condition. The records do not establish that she had a significant clinical worsening requiring immediate care before she returned to the Plans service area. In sum, based on the patients clinical presentation she did not meet prudent layperson criteria for urgently needed services. The Health Plans denial should be upheld.Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 53-year-old female enrollee has requested authorization and coverage for a referral to an orthopedic doctor.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The initial treatment for bunions and similar problems is non-surgical, including the use of shoe modifications, inserts, and pads. Surgical consultation is indicated when these measures fail and there is continued pain and functional limitation.  Although there are a large number of different procedures available, the decision for surgery should follow the failure of non-surgical techniques.  In this case, there is no documentation of the presence of a skeletal abnormality on x-ray, and there is no documentation of efforts at non-surgical management. The current medical evidence does not support the requested services in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested 22 hours a week of direct applied behavioral analysis (ABA) treatment, 12 hours a month of supervision and 6 hours a week of parent consultation for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. Multiple studies have documented ABA therapy as significantly improving motor, verbal, and social interactive skills in autistic children. The value of ABA as the only effective behavioral treatment has been documented by multiple authors (Vismara and Rogers). However, when reviewing ABA as effectively applied to teenagers and adults, there is limited literature addressing the question of duration and frequency of therapy as the patient reaches adolescence and adulthood. Rather than to continue individual ABA therapy, the tendency is to expand social and behavioral skills in group and school settings.  This 16-year-old patient has been receiving ABA therapy for at least 7 years. While intensive ABA services are not likely to result in further significant improvement, continuation of ABA therapy at a reduced frequency is medically necessary to maintain the patients current level of function. As such, continued ABA therapy at a frequency of 5 hours per week of direct ABA therapy, 1 hour per week of supervision and 1 hour per month of parent consultation is medically necessary to maintain the patients present level of function.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Remicade infusions every four weeks. The request for Remicade 10 mg/kg every four weeks is supported as medically necessary for treatment of this patient. Remicade doses higher than 10 mg/kg every eight weeks can be effective for patients with Crohns disease, and may prevent disease complications. Dose intensification is commonly required during therapy with Remicade, and can include increased dosing and frequency. In addition to clinical trial data, there is other literature to support Remicade at 10 mg/kg every four weeks, with improved response in well-selected patients. This patient has experienced uncontrolled symptoms related to Crohns disease before Remicade infusions while on a dose of 10 mg/kg every eight weeks. Testing revealed a low trough Remicade level, which indicates a risk for more severe complications. The American Gastroenterological Association (AGA) guidelines recommend that in patients with a low Remicade level, the dose should be increased. Additionally, perianal Crohns disease requires higher Remicade trough levels to permit healing. Continuation of the Remicade dose of 10 mg/kg every eight weeks may result in a disease flare or complications for this patient, who has failed treatment, and had an initial good response to Remicade. Switching to another medication given the patients presentation and partial response to Remicade might result in loss of disease control. Given these findings, the requested Remicade infusions every four weeks are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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 subspecialty 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 Glumetza. Recent literature explains that metformin is a widely used medication which is often the first line of therapy for the treatment of type 2 diabetes. While metformin is an effective medication, it may be associated with gastrointestinal side effects, such as diarrhea. Studies indicate that extended release metformin has better gastrointestinal tolerability and fewer side effects as compared to immediate release metformin, with similar efficacy regarding anti-hyperglycemic effects. Therefore, the requested Glumetza is medically necessary for treatment of this patients condition. Final Result: The physician reviewer determined that the requested medication is medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested pulmonary vein ablation for treatment of atrial fibrillation.  Findings:  Three physician reviewers found that pulmonary vein ablation has become an accepted tool for the management of refractory symptomatic atrial fibrillation. While long-term efficacy data is still evolving, clinical practice supports its use in symptomatic patients that have failed traditional medical therapy. Alternative treatments such as flecainide, amiodarone, diltiazem, digoxin and the mini-maze have already been tried without success.