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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 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 and the Infectious Diseases Society of America, 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, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Non-cirrhotic patients with a viral load less than 6,000,000 IU/mL, such as this patient, can be treated for eight weeks. The guidelines cite data showing reduced survival with delayed treatment.  Therefore, Harvoni for eight weeks is medically indicated 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for combined treatment with Opdivo (nivolumab) and Yervoy (ipilimumab).The combination of Opdivo (nivolumab) and Yervoy (ipilimumab) is not approved by the U.S. Food and Drug Administration for the treatment of metastatic cervical cancer. Moreover, the combination use is not supported by major drug compendia or the medical literature. Although initial data from the study conducted by Naumann and colleagues suggest benefit, the combined treatment use in cervical cancer requires more robust studies before it can be recommended. Thus, the combined treatment with Opdivo and Yervoy is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications 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 sub-specialty certification in medical 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: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee has requested residential treatment facility level of care services for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient entered residential treatment with a body mass index of 17.8 at 88% of her ideal body weight. She was not losing weight rapidly or engaging in uncontrolled binging or purging behavior. She was not in metabolic danger. During residential treatment, there were no suicidal ideations, evidence of withdrawal or complications from anorexia noted. The patient did not have severe co-morbid psychiatric disorder, mania, suicidality, psychosis or aggression during the period at issue. She was not at risk of harm to herself or others and could have been safely and effectively treated in a less intensive setting throughout her stay.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for spinal magnetic resonance imaging (MRI). Findings: The AIM criteria for spine imaging states that one of the requirements is conservative management, which is documented in this patients records. An additional AIM requirement is evidence of objective weakness or sensory abnormality corresponding to a dermatome, reflex abnormalities, or spasticity. The patients strength, sensation, and reflexes were reportedly normal on the most recent physical examination before the MRI. The patients reported pain was in the gluteal region and behind the thigh, which is where the S1 and S2 nerves innervate. Both nerves continue to innervate the back of the lower extremity below the level of the knee, which was not present in this patients clinical setting. Therefore, the patients nerve pain was not likely due to S1 or S2 nerve compression. The American College of Radiology (ACR) requirements for low back pain imaging state that for patients with subacute or chronic pain, MRI of the lumbar spine may be appropriate. However, this patients pain was in the gluteal region rather than lower back and not in a dermatomal distribution, which did not support an indication for MRI. Therefore, the spinal MRI was not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 neuroradiology with subspecialty certification 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 for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 2b.According to recent guidelines, 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 2b patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. A trial showed a 99% cure rate with eight weeks of treatment. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks 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: The patient has requested authorization and coverage for armodafinil. Researchers noted, central hypersomnias are manifested by excessive daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms. Thus, evaluation with a sleep study and multiple sleep latency test (MSLT) is used as an objective tool for diagnosis of narcolepsy and hypersomnias. This patients records include adequate documentation to support a diagnosis of idiopathic hypersomnia given the results of his sleep study and MSLT test. The patient has reportedly benefited from armodafinil, which is indicated for idiopathic hypersomnia. For these reasons, the requested armodafinil is medically necessary for 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 board certified in internal medicine with subspecialty certification in sleep medicine 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 breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that this revealed no evidence of cancer.  The Health Plan has denied reimbursement for breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: The reviewers determined that the service 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. 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 48-year-old male enrollee has requested participation in the Mayo Clinical trial MCO48A for treatment of his multiple myeloma.  Findings:  Two physician reviewers found that there is no available informative data regarding the safety and efficacy of the therapeutic regimen in the proposed trial.  The crux of the matter has to do with the Phase I status, which automatically infers that there is little or no data, other than an empiric rationale, that this approach will benefit the patient more than standard therapy. This patient appears to be eligible for high-dose therapy in-plan.  In the evaluation by the Mayo Clinic physicians, standard/autologous transplant was recommended, after a trial of debulking using a Velcade-anchored regimen, a plan which the patient is presumably following. In sum, no data is available or has been presented that argues for participation in a Phase I trial and against standard high dose chemotherapy and stem cell rescue in this patient, only an urgency that he move toward autologous transplant in a timely fashion.
Appeal type: Experimental/Investigational
Decision: Overturned

A 29-year-old female enrollee has requested bilateral inferior turbinate cautery for treatment of her hypertrophic bilateral inferior turbinates.  Findings:  Three physician reviewers found that the medical records documented a deviated nasal septum and hypertrophy of the turbinates.  Surgery was performed on the date in question, and this included correction of the deviated nasal septum and cautery to reduce the turbinates. Nasal turbinate hypertrophy is a common condition which often accompanies and complicates the obstruction caused by a deviated nasal septum.  Correction of the deviation alone is often insufficient in relieving the patients symptoms.  According to the operative report, the turbinates were reduced by cautery, and this technology has been used for several decades.  All told, in this patients case, bilateral inferior turbinate cautery was likely to have been the most efficacious treatment option.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested H.P. Acthar Gel for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The available medical records do not provide documentation that supports a diagnosis of rheumatoid arthritis.  There is no data to support this diagnosis.  There is also no documentation that supports a diagnosis of cytokine deficiency that would potentially preclude the use of a biologic agent.  The available medical records do not provide supporting documentation that the patient has a steroid responsive condition.  All told, the requested H.P. Acthar Gel 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 enrollees medical condition.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing performed on 2/1/17 for evaluation of the enrollee, who has a history of elevated blood pressure and cholesterol.Findings:  Two physician reviewers found that in this circumstance, guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2 (Lp-PLA2), myeloperoxidase, sub-classifications of low density lipoprotein, high density lipoprotein, subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results are lacking. Final Result: Two reviewers determined that the testing 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 cardiovascular disease and are actively practicing. The reviewers are an experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 2-year-11-month-old female with multiple medical problems, including possible Mobius syndrome, arthrogryposis, restrictive lung disease, and gastrostomy dependence are requesting authorization of Synagis.Reviewers Findings:  The reviewing physician found that children with neuromuscular conditions who have a poor cough due to weak or ineffective respiratory muscles and cannot adequately clear respiratory secretions are included in patients for whom palivizumab prophylaxis (Synagis) would be appropriate. This patient would fall into this category.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total left knee replacement surgery. The patient should provide documentation of failure of non-operative treatments such as physical therapy and medications, as well as exercise and weight loss, when indicated. This patient presents with chronic left knee pain that has been reported as moderate, intermittent, and recurrent. She has an antalgic gait and uses a knee brace. The records include detailed documentation of recent, reasonable and comprehensive non-operative treatment. Clinical examination findings are consistent with imaging evidence of chondromalacia patella and minimal medial femorotibial joint space narrowing. There are only minimal findings of osteoarthritis. A recent evaluation with an orthopedic surgeon did not recommend surgical intervention at that time. Given these findings, the requested total left knee replacement surgery 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for combination therapy of Opdivo (nivolumab) plus Yervoy (ipilimumab).Medical literature does not support that the requested combination therapy is medically necessary. The combination of Opdivo (nivolumab) and Yervoy (ipilimumab) does not have available studies to support its use at this time. The recent article in the New England Journal of Medicine on Opdivo (nivolumab) and Yervoy (ipilimumab) involved first line treatment, which is the initial treatment of a given type and stage of cancer. In this case, however, the patient has recurred one year after the completion of first line treatment. There is not enough data in the literature at this time to support the use of combination therapy with Opdivo (nivolumab) and Yervoy (ipilimumab) following first line treatment. Under these circumstances, combination therapy of Opdivo (nivolumab) and Yervoy (ipilimumab) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested combination therapy of medications 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 medical 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 reimbursement for the Foundation One testing provided for evaluation of the enrollees stage IV colon cancer. Findings: The three physician reviewers found that the utility of Foundation One testing has not been definitely proven in the current peer-reviewed medical literature. To demonstrate clinical utility of panel genetic testing such as Foundation One assay, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. No such trials have currently been published. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. However, the National Comprehensive Cancer Network (NCCN) has endorsed KRAS and NRAS testing to help determine appropriate therapy. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is not routinely recommended and the utility of the KRAS and NRAS portions of the Foundation One assay are supported as beneficial in this clinical setting. Accordingly, the KRAS and NRAS portions of the Foundation One testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Foundation One test was not likely to be more beneficial for evaluation of your medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the testing 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 partially 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: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee requested authorization and coverage of chiropractic care to treat a pinched nerve. The Health Plan denied the request indicating that the chiropractic care is not medically necessary.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested a Flexitouch pneumatic compression device as opposed to the IC-BAP-DL Bio Arterial Plus device for treatment of her lymphedema, inability to control swelling, and compromised skin integrity.  Findings:  The physician reviewer found that the records submitted for review lack evidence that the patient would benefit from the requested Flexitouch pneumatic compression device over standard pneumatic compression devices. A standard pneumatic compression device has not been used due to concerns over skin integrity. However, the requested Flexitouch would likely present the same skin risks. Based on the records provided for review, there is inadequate documentation supporting the medical necessity of the requested Flexitouch pneumatic compression device.