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

A 58-year-old female enrollee has requested  bariatric surgery for treatment of her obesity, obstructive sleep apnea, and osteoarthritis.  Findings:  The physician reviewer found that although this patient meets many of the basic requirements commonly used to determine if a patient is a candidate for bariatric surgery, she has not demonstrated thorough compliance with preoperative requirements (Eldar, et al; Tariq and Chand). The patient is morbidly obese with a body mass index that exceeds 40. She has comorbid medical conditions related to her obesity including obstructive sleep apnea, osteoarthritis, depression, and GERD. However, she has demonstrated a history of poor compliance, missed appointments, and marginal commitment to the program. As a result, she has not been cleared for surgery by the bariatric program. A health psychologist has not endorsed her as a suitable candidate for bariatric surgery. The patient would be best suited to continue to work on managing her depression and committing to the pre-surgical diet recommendations. Patients who provide documentation of compliance prior to requesting bariatric surgery are likely to be more successful at durable weight loss and lasting health benefits following surgery (Bauchowitz, et al). For these reasons, the requested bariatric surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested 24 weeks of Harvoni and ribavirin for treatment of his hepatitis C.  Findings:  Three physician reviewers found that this patients clinical record, laboratory results, and imaging confirm cirrhosis.  Per the medical records, he is beginning to show evidence of decompensation from his liver disease including encephalopathy and volume overload.  The current medical evidence supports treatment of patients with cirrhosis with Harvoni with or without ribavirin for 24 weeks if they failed sofosbuvir with simeprevir.  All told, 24 weeks of Harvoni and ribavirin is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic testing for evaluation of her medical condition. Findings: Two physician reviewers found that there are now multiple gene assays to further refine our understanding of the biology of an individuals breast cancer.  The current guidelines make reference to the Oncotype DX assay.  However, the MammaPrint, a 70 gene assay, has been fairly well-accepted by the oncology community, as an alternative to the Oncotype DX assay, in determining the need for adjuvant chemotherapy.  This assay does give an estimate of the risk of recurrence, and thereby is useful in considering adjuvant chemotherapy.  Thus, there is sufficient support for the MammaPrint portion of the services at issue.  TargetPrint determines the activity of a particular gene, which might be a superior assay for certain signatures, but as of yet its clinical utility has not been proven.  BluePrint is an assay designed to classify a patients breast cancer into specific molecular subtypes, such as luminal or basal-like types.  There is no known additional clinical benefit from this assay, above and beyond the MammaPrint assay.  In sum, the MammaPrint portion of the services at issue was likely to have been more effective than other modalities.  However, the superior efficacy of the remainder of the services at issue has not been established.  Final Result: Two reviewers determined that 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: All three physician 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 59-year-old female with a history of osteoporosis. Findings:  The physician reviewer found that bone densitometry of the hip and lumbar spine revealed a hip T-score of -2.2 and lumbar spine T-score of -2.8. The bone mineral density of the left hip was noted to be osteopenic, and the bone mineral density of the lumbar spine was noted to be osteoporotic. In a letter, the patients provider noted a bone density test in 2017 revealed osteoporosis of the lumbar spine, and the left hip was osteopenic. The patient had previously been treated with Evista. She has requested authorization and coverage for a bone density test (dual energy x-ray absorptiometry, also called DEXA scan). The Health Plan denied the request and reported that the requested services are not medically necessary for the evaluation of this patient. At issue in this patients case is whether a bone density test (dual energy x-ray absorptiometry, also called DEXA scan) is medically necessary for the evaluation of the patients medical condition. Per the International Society for Clinical Densitometry, bone mineral density (BMD) testing is indicated for women 65 years of age and older and post-menopausal women younger than age 65. A bone density test is indicated if the patient has a risk factor for low bone mass, such as low body weight, prior fracture, high-risk medication use, and a disease or condition associated with bone loss. BMD testing is also indicated for women during the menopausal transition with clinical risk factors for fracture, such as low body weight, prior fracture, or high-risk medication use. Finally, BMD testing is indicated for anyone not receiving therapy in whom evidence of bone loss would lead to treatment. In this case, the patient is premenopausal with a previous history of osteoporosis based on 2010 and 2017 DEXA scans.  Previous therapy has included Evista. The medical evidence supports the requested services in this clinical setting. Therefore, a bone density test (dual energy x-ray absorptiometry, also called DEXA scan) is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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

The patient is a 41-year-old woman with a twin pregnancy following a successful IVF cycle. Her EDC is in January 2007. She has a history of chronic hypertension. Due to her history, she was referred to a perinatology group, who has followed her in consultation with her obstetrician. During the consultative follow-up, she underwent an ultrasound at the perinatology office in July 2006, at 14 weeks gestation for fetal anatomy studies, advanced maternal age and twin pregnancy. The ultrasound was normal for dates. A repeat ultrasound was performed in August 2006 at 18 weeks gestation for the same indications. The ultrasound was again normal for dates. The cervix was also screened for changes consistent with cervical incompetence, and there was no evidence of that finding. The perinatologist, in the second report, recommended that the patient undergo serial ultrasound scans every 4 weeks until 33 weeks, to screen for the presence of intrauterine growth restriction which is at risk in twin gestations. He also recommended these scans on the basis of the risk of prematurity due to the increased risk for the onset of premature labor or cervical incompetence. The Health Plan has approved the ultrasounds at a local hospital within the network and has denied coverage for in-house scans at the perinatologists office as requested by the patient.With a history of twin pregnancy, IVF multiple pregnancy and chronic hypertension, it is within the standard of care to recommend serial ultrasounds to monitor the patient. These ultrasounds should be performed at a facility that demonstrates competence and experience in perinatal ultrasound. In addition, the facility must offer the ordering perinatologist immediate, stat results early on the day of the examination. It is essential that changes indicating an increased risk of premature labor or cervical incompetence be reported immediately to the subspecialist. No evidence has been presented that the diagnostic facility approved by the Health Plan does not offer the above level of service. Therefore, it is medically reasonable and appropriate for the patient to undergo ultrasound examinations at the approved facility as long as the patients perinatologist is provided with the diagnostic results on an immediate basis.Based upon the information set forth above, I have determined the requested in-house ultrasounds are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
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. Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being 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. Therefore, the digital breast tomosynthesis has been established as 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for relationship development intervention treatment services. There is a lack of evidence in current medical literature on the effectiveness of relationship development intervention (RDI). Applied behavioral analysis (ABA) services are currently the most evidence-based strategy for treating autism, with some evidence supporting other interventions such as cognitive behavioral therapy and exercise. In this case, the records do not reflect specific information what concerns will be targeted during RDI treatment, how they will be targeted, and at what intensity. Given the lack of evidence supporting the effectiveness of RDI, and lack of documentation to determine the type, frequency, and duration of RDI in this case, the requested services are not medically indicated. Therefore, relationship development intervention treatment services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychology 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 his hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment regimen of 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 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. Further, a modeling study based on the Swiss HIV cohort also demonstrated that waiting to treat HCV at Metavir fibrosis stages F3 and F4 resulted in 2- and 5-times higher liver-related mortality respectively. Moreover, compared to those with HCV infection alone, persons with HCV/HIV co-infection have a higher rate of HCV persistence, faster progression to cirrhosis and end-stage liver disease, and higher HCV RNA levels. Persons co-infected with HCV/HIV also had lower responses to peginterferon and ribavirin than those with HCV infection alone, an observation largely explained by the higher baseline HCV RNA levels. Clinical trial data in HIV infected individuals with HCV genotype 1 or 4 infection have demonstrated the safety and efficacy of Harvoni. As such, the requested course of treatment with Harvoni is medically necessary for this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement for air and ground ambulance services. Findings:  The physician reviewer found that acute leukemias and their treatment are major emergencies in internal medicine. The standard of care is to use multi-agent chemotherapy followed by allogeneic hematopoietic stem cell transplant for patients with matched bone marrow. In this case, the patient was treated with the CALGB 9111 protocol, which involves remission induction, intensification, followed by maintenance. After induction, she achieved a complete remission by bone marrow exam. On subsequent relapses she received blinatumumab and CAR-T therapy at UW. All of her other care was at UCSF. She was received at UCSF after discharge from UW as an inpatient with palliative care. Her active medical issues prevented her from being treated as an outpatient. Furthermore, her transplant was performed at UCSF and those providers were familiar with her case. The social infrastructure is an essential component of palliative care. Air transport as used in this case was medically appropriate and necessary for this patients care. As such, the air and ground ambulance services provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification 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: Overturned

A 57-year-old female enrollee has requested for 4-Aminopyridine, a compounded medication for treatment of her multiple sclerosis.    Findings:  The physician reviewer found that there is literature support for the use of fampridine in this patient population. Fampridine is medically appropriate for this patient in light of her progressive symptoms, which have been refractory to other therapies but showed improvement with fampridine.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for Kallmann Syndrome panel genetic testing.Findings:  Three of three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Many underlying conditions can lead to primary amenorrhea in young women. Typically, the diagnosis of Kallmann Syndrome is suspected by the pediatrician and made by a pediatric/adult endocrinologist. As this is a genetic condition, testing for the various different genetic forms of this disease may also assist in making the diagnosis. From the pediatric endocrinologist perspective, an accurate diagnosis needs to be obtained. Clinical presentations similar to Kallmann Syndrome can occur from other causes disease process. In Kallmann Syndrome, the genetic presentation can have a variety of different clinical manifestations and it is important to have an idea of the specific genetic presentation in the management of these patient in order to help select the correct management and mange the disease process. Once pubertal maturation is achieved, if Kallmann Syndrome subjects wish to be fertile, either injections of pituitary hormones (the gonadotropins, LH and FSH) or in some instances, therapy with the synthetic peptide, GnRH, whose deficiency causes these syndromes, are required to induce the sex organs (testes or ovaries) to make sperm (males) or eggs (females). While Kallmann Syndrome is usually life-long, about 10-15% of patients may experience a recovery of their hormonal system, the reasons for which currently remain unclear. In this case, the patients presentation warrants genetic evaluation to help confirm diagnosis and to help guide management in this rare condition. Accordingly, Kallmann Syndrome panel genetic testing is likely to be more beneficial than any other available standard testing for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment 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 obstetrics and gynecology 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 reimbursement for the Foundation One gene panel testing for evaluation of the enrollees recurrent papillary thyroid carcinoma. Findings:  Two physician reviewers found that Papillary thyroid cancer is a frequent histologic subtype of thyroid cancer and data suggests that BRAF mutations are frequent. This is notable since the presence of the mutation provides significant prognostic information and potential targeted therapies. The authors reported that the regimen selected by molecular profiling offered a 27% survival advantage. This patients tumor tested positive for BRAF mutation and PIK3CA, which supports consideration of kinase inhibitor therapy. Final Result: Two reviewers determined that 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 overturned. Credentials/Qualifications: All three 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 authorization and coverage for implantation of Vivistim Paired vagus nerve stimulation (VNS) system. The current mainstay of treatment for neurological deficits following stroke, including arm dysfunction, is intensive therapy. Arm dysfunction is particularly debilitating and can have major impacts on a patients quality of life. The records provided for review document that this patient sustained an ischemic stroke with severe arm dysfunction. Despite years of intensive therapy, her condition has only modestly improved. She has well documented deficiencies in functioning and her ability to perform activities of daily living (ADLs). The patients provider has recommended treatment with a Vivistim VNS system. Medical literatures performed a randomized controlled trial to evaluate the effect of VNS paired with rehabilitation in patients with severe upper extremity dysfunction after stroke. The authors concluded that after 90 days, a clinically meaningful difference was achieved in nearly 50% of the VNS-treated group. Similarly, researchers reported that, VNS paired with rehabilitation was acceptably safe and feasible in participants with upper limb motor deficit after chronic ischemic stroke. Given this support, the requested implantation of Vivistim Paired VNS system procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested implantation of Vivistim Paired VNS system 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in neurological surgery 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.