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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present.  However, the guidelines state that lack of NS5A resistance testing should not be an impediment to coverage, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg for 12 weeks is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, children who received therapy had far greater communication skills than those children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his 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, 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 1 patients should be treated with Viekira Pak, or with Harvoni.  Both medications are U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  There are no head-to-head direct comparison trials showing that Harvoni is superior to Viekira Pak.  In this patients case, no contraindication to Viekira Pak/ribavirin is provided.  For this reason, although hepatitis C treatment is needed in this case, Harvoni is not supported over Viekira Pak.  For these reasons, the requested treatment with Harvoni 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: Urgent Care
Decision: Upheld

A 51-year-old female enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that vital signs were within normal limits. The patient did not appear to be in distress, but was ambulating with obvious discomfort. No pelvic deformity was noted. Distal neurovascular function was intact. X-rays of the patients pelvis and left hip were negative for any fracture or dislocation. The patient was diagnosed with left hip pain. She was advised that this pain could be caused by a lumbar radiculopathy. The patient was discharged with advice to follow-up with her primary care provider for possible physical therapy or orthopedic referral.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  Their conclusions report that although results are suggestive that transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends. Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  All told, the superior efficacy of the services at issue has not been established in this clinical scenario. Transcranial magnetic stimulation was not and is not likely to be more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee requested authorization and coverage of an MRCP. The Health Plan denied the request indicating that the requested MRCP is not medically necessary for the evaluation of the enrollees abdominal pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRCP is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90/400 mg for 12 weeks for treatment of the enrollees hepatitis C.Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases 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.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  Per the guidelines, non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines recommend either Harvoni or Zepatier as acceptable therapy.  There is a need for NS5A resistance testing prior to Zepatier in genotype 1a. The current guidelines cite data showing reduced survival with delayed treatment. For these reasons, although treatment of hepatitis C is needed, the Health Plans alternative of Zepatier is medically appropriate.Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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 44-year-old female enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma.  Findings:  Two physician reviewers found that the records provided for review do not include documentation of spirometry or peak flow readings, and do not specify the frequency of treatment with oral steroids or visits to the emergency department. In addition, bronchial thermoplasty remains unproven in terms of its long-term effectiveness without clinical studies on large groups demonstrating its equivalence or superiority to standard alternatives. Therefore, the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his 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.  Per the guidelines, non-cirrhotic, treatment-experienced, genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  All told, Harvoni for 12 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

A 55-year-old male enrollee requested authorization and coverage of proton beam therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as extremely dense.  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.  Thus, digital breast tomosynthesis is likely to have been more effective than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue is 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One injections to both knees. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by Maheu and colleagues, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, and a reduction in use of concomitant analgesia by up to 50%. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee pain due to osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, the requested injections to both knees are medically necessary to treat the patients medical condition.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 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: Overturned

A 45-year-old male enrollee requested authorization and coverage of the medication Viagra for the treatment of erectile dysfunction.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that 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 compared to two-dimensional imaging alone.  Thus, the addition of 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that 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 compared to two-dimensional imaging alone.  Thus, the addition of 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 52-year-old female enrollee has requested 35 treatments of transcranial magnetic stimulation (TMS) for treatment of the stated condition of major depressive disorder.  Findings:  Two physician reviewers found that there is history of manic episodes for this patient, which is particular to bipolar disorder, rather than to unipolar depression. There is a paucity of large scale, randomized data to support the efficacy of TMS in the treatment of bipolar disorder. Additionally, there is inadequate evidence to support TMS as a more efficacious antidepressant therapy than electroconvulsive therapy. There are not randomized studies comparing TMS to ECT for treatment resistant depression or bipolar disorder. In this case, there is a lack of documentation that the patient has been tried on ECT or other standard therapies such as an adequate trial of evidence based psychotherapy. All told, there is insufficient evidence that TMS therapy is likely to be more effective for this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidural steroid injections for treatment of her medical condition.   The physician review found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis.  The patients physical examination does not show evidence of radiculitis, and her chronic pain condition is not consistent with this diagnosis.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 anesthesiology with sub-specialty certification in pain 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.