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 Botox (botulinum toxin) every 12 weeks for one year.The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; when there are four or more attacks per month; or when there is a contraindication to, failure, or overuse of acute treatment. Currently, Botox is approved for chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages of injectable therapies. (American Headache Society). In 2016, the American Academy of Neurology updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. A 2018 review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine by Frampton and colleagues noted that the totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics (Frampton, J. and Silberstein, S.). In this case, the patient has a history of chronic migraines that did not respond to oral preventive medications. The use of botulinum toxin in this case has proven to be effective in increasing the number of headache-free days. Therefore, the requested Botox (botulinum toxin) every 12 weeks for one year is medically necessary for the treatment of the patients medical condition.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as in this case.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiation therapy for treatment of the enrollees prostate cancer. .Findings:  The physician reviewer found that The physician reviewer found that stereotactic body radiation therapy (SBRT) is not likely to be more beneficial than available standard therapy, conventionally fractionated intensity modulated radiation therapy (IMRT). Outcome data for SBRT at this time is limited to five to six years follow-up. In a pooled analysis of separate phase II trials from eight institutions (1100 patients) by King and colleagues, the authors noted that the five-year biochemical disease-free survival was 84% for intermediate-risk patients treated with SBRT. Overall, the outcome data appear similar to conventionally fractionated radiotherapy, but do not demonstrate that SBRT is likely to be more beneficial. Additionally, longer follow-up would be optimal due to the long natural history of prostate cancer. The idea of SBRT being equivalent to conventionally fractionated IMRT is summarized by the most recent National Comprehensive Cancer Network guidelines which note extremely hypofractionated image-guided IMRT/SBRT regimens (6.5 Gy per fraction or greater) are an emerging treatment modality with single institutional and pooled reports of similar efficacy and toxicity to conventionally fractionated regimens. They can be considered as a cautious alternative to conventionally fractionated regimens at clinics with appropriate technology, physics, and clinical expertise. Overall, the requested SBRT is not likely to be more efficacious than other available treatment modalities. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in radiation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab (Rituxan) for treatment of her lupus.  Findings:  The physician reviewer found that There is a lack of support in the documentation provided and in the medical literature for the requested medication in this clinical setting.  This case involves a patient with active neuropsychiatric SLE. A review by researchers looked at the EXPLORER trial for depleting B cells in patients with moderate to severely active extra-renal SLE. Their study did not demonstrate a difference between placebo and rituximab in the primary and secondary end points. They noted the following, A beneficial effect of rituximab on the primary end point was observed in the African American and Hispanic subgroups. Safety and tolerability were similar in patients receiving placebo and those receiving rituximab. They concluded that Further evaluation of patient subsets, biomarkers, and exploratory outcome models may improve the design of future SLE clinical trials.  A review by other researchers evaluated the LUNAR study as to the, efficacy and safety of rituximab in a randomized, double-blind, placebo-controlled phase III trial in patients with lupus nephritis treated concomitantly with mycophenolate mofetil (MMF) and corticosteroids.  They concluded Although rituximab therapy led to more responders and greater reductions in anti-dsDNA and C3/C4 levels, it did not improve clinical outcomes after one year of treatment. The combination of rituximab with MMF and corticosteroids did not result in any new or unexpected safety signals. More recently, a systemic review by  other researchers  showed some short term benefits in patients with extra-renal SLE.  The authors concluded that Rituximab has been shown to be safe and effective in the treatment of non-renal SLE, especially in terms of disease activity, immunologic parameters and steroid-sparing effect. However, it can only be recommended for organ-specific manifestations such as arthritis and thrombocytopenia. High-quality studies are needed in order to consider the long-term effects of re-treatment on different organ-specific manifestations. The review failed to demonstrate significant improvement for patients with neuropsychiatric SLE like in this patients case. While the records indicate that she has failed Plaquenil and cyclophosphamide, the results of such medications are not noted.  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 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: Overturned

A 37-year-old male enrollee has requested right shoulder arthroscopy, SLAP repair, capsular plication and decompression surgical procedure for treatment of his right shoulder pain.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  This patient is status post motorcycle accident with 25 foot fall, and he was found to have significant SLAP lesion via imaging.  He was appropriately treated conservatively with physical therapy with some improvement in range of motion.  More recently, the patient was found to have ongoing decreased range of motion and decreased strength of the right shoulder as well as positive OBriens test, crank test, and impingement testing.  The medical evidence supports the requested services in this clinical setting.  All told, right shoulder arthroscopy, SLAP repair, capsular plication and decompression surgical procedure are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female has requested reimbursement for the genetic testing. Cell free fetal DNA testing has been proven to be beneficial in certain high risk populations. In addition, cell free fetal DNA technology may be appropriate based on a patient. However, in this case, the patient does not have any risk factors such as advanced maternal age, or personal, familial, or ethnic risk factors for the disorders tested. All told, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for the residential treatment services provided. Findings:  The physician reviewer found that the records indicate that the patient was cooperative with staff and her activities of daily living were intact. The medical records do not support active suicidal ideation or psychosis during the disputed period. The documentation indicates that the patient was functioning well and expressed motivation to understand her substance use and maintain her sobriety. She had no active serious medical problems and no symptoms of substance withdrawal. She appeared to be insightful into her need for treatment despite initially not wanting to be at the residential treatment center. According to the American Society of Addiction Medicine (ASAM) criteria, the residential treatment services provided were not medically necessary. Overall, the patients presentation suggests risk rating scores in the range of zero to two, which is consistent with intensive outpatient services (IOP) of nine or more hours of service per week. Further, a study noted that IOPs are an important part of the continuum of care for alcohol and drug use disorders. They are as effective as inpatient treatment for most individuals seeking care. Thus, the patient could have been treated in a less restrictive setting safely and effectively as she did not have severe symptoms that necessitated 24-hour residential care. Accordingly, the residential treatment services provided were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for admission to an acute neurorehabilitation treatment facility. Findings:  The physician reviewer found that this patient has received two weeks of acute level inpatient rehabilitation and ten days of skilled nursing facility level rehabilitation. The documentation indicates that this patient has progressed functionally with his therapies. However, the submitted records indicate that this patient only had minimal functional gains at the skilled nursing facility (SNF) level of rehabilitation. His function upon admission to SNF was similar to what it was when he discharged from acute rehabilitation. While this patient has persistent functional deficits and significant safety concerns, the medical literature does not support the requested services at an acute neurorehabilitation facility. This patient will benefit from skilled level outpatient physical therapy, occupational therapy, and speech therapy to work on safety, endurance, ambulation, balance, and ADLs. The outpatient therapies will also benefit his mild cognitive deficits. For these reasons, the requested authorization and coverage for admission to an acute neurorehabilitation treatment facility is not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation 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 male enrollee requested a 12 week course of Harvoni for medical treatment of his hepatitis C virus genotype 1b. Findings:  Three physician reviewers found that the guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) for treating patients with hepatitis C virus support the safety and efficacy of Harvoni in this clinical setting. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. Thus, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing for inherited thrombophilia for treatment of her medical condition. Three physician reviewers found that according to the American Congress of Obstetricians and Gynecologists (ACOG) practice recommendation, testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. There is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin (LMWH) prevents recurrence in these patients. In addition, there is insufficient evidence of an association and, therefore, insufficient evidence to either screen for or treat women with inherited thrombophilias and obstetric histories that include complications such as fetal growth restriction or preeclampsia. The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first degree relative with a history of high risk thrombophilia, which was not presented in this case. Therefore, the genetic testing for inherited thrombophilia was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was 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 obstetrics and gynecology 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 parent of an enrollee has requested authorization and coverage for 11 hours per week of direct applied behavioral analysis (ABA) services and 10 hours per month of enhanced supervision services for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that based on the clinical documentation provided for review, the request for 11 hours per week of direct ABA services and 10 hours per month of enhanced supervision services has been established as medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. A study found that children receiving more than 27 hours per week of ABA and starting earlier were more likely to have optimal outcome. There was a decrease over time in the intensity, but a notable difference above 27 hours per week. Another study found that longer duration and higher intensity ABA led to more goals being met and more skills mastered. In addition, researchers found that pivotal response treatment (PRT), which is similar to ABA therapy is effective in reducing aggression in school age children. In this case, the patient has made progress with goals and has learned many skills, but the patient still continues to have aggression and non-compliance which support ongoing ABA therapy at the proposed frequency. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 four-year-old female has requested speech therapy for treatment of her autism. Findings:  The physician reviewer found that the medical literature supports speech therapy in the autistic population. 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, those who received therapy had far greater communication skills than those 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.