Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensity modulated radiation therapy for treatment of his medical condition. Three physician reviewers found that because surgery for cervical esophageal cancer would require a pharyngo-laryngo-esophagectomy, chemoradiation is the treatment of choice.  The intensity modulated radiation therapy technique allows the optimization of target volume coverage while allowing reduction of the dose to surrounding organs at risk.  Therefore, an increased total dose could be achieved with better coverage of the target volume.  In a study comparing three-dimensional conformal radiation versus intensity modulated radiation therapy, Freilich and colleagues noted that intensity modulated radiation therapy-based chemoradiation for esophageal cancer resulted in significantly less toxicity.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested intensity modulated radiation therapy is likely to be of greater benefit than other treatment options.  Final Result: Three 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: All three reviewers are board certified in radiation 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

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that an extensive review of the available peer reviewed medical literature, including a meta-analysis by Law, et al., noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. Statistically greater improvement was found with intensive direct speech and language therapy delivered by speech and language therapists over an eight month period when compared to no intervention or nursery-based intervention. Thus, speech therapy in this case is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay.Findings:  Three physician reviewers found that this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma assay was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 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: Upheld

A 59-year-old female enrollee has requested for Botox injections for treatment of her intractable migraine headaches.   Findings:  Two physician reviewers found that there is no report of muscle hypertrophy, sensory trick, or indication of sustained abnormal posture despite muscle spasm. Cervical dystonia (CD) is a condition characterized by abnormal involuntary excessive muscle activity, with spasms, muscle hypertrophy, altered posture, and altered mobility. It is often associated with pain, may have dystonic tremor components, and often, patients have found sensory tricks that partly reduce symptoms. While Botox is indicated for the treatment of CD, the patients findings are not consistent with a diagnosis of CD. All told, the submitted records do not support the use of Botox in this case.
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: Three 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 dense breasts. 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. Given the support cited above, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50-100 mg tablets for 12 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. 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 or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50-100 mg tablets for 12 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 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 49-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that TMS has FDA approval for the indication of major depression that has failed to respond to an adequate trial of antidepressant medication. The indication is for acute treatment only, not for maintenance. In the study that the FDA used to approve the TMS device (OReardon et al.), and an independent re-analysis of that studys data (Lisanby, et al.), patients with a higher degree of antidepressant resistance than a single antidepressant failure do not consistently show a response to TMS greater than sham treatment. These findings were confirmed by two independent clinical trials (George, et al. and Avery, et al.).  In addition, the response rate and effect size of the response to TMS for patients who have failed a single antidepressant is comparable to, not markedly superior to, the response expected from another antidepressant trial or a trial with augmentation. (Lisanby et al., OReardon, et al. and Rush). Further, the study of maintenance TMS involved the use of TMS as a supplement to medication maintenance and was considered to be of unproven efficacy (Janicak, et al.).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her 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, treatment-naive 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.  For these reasons, the requested treatment with Harvoni for 12 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 Harvoni 90-400 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni 90-400 mg for 12 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. Fulfills 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the exam had been done with the two dimensional technique alone.  Final Result: Three 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 reviewers are board certified in diagnostic radiology 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: Upheld

A 47-year-old female enrollee requested authorization and coverage of a hysterectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroids.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested authorization and coverage of a referral to an urologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees bladder control problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin for the 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 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. For these reasons, the requested treatment with Viekira Pak and ribavirin is medically necessary for the treatment of this patients hepatitis C infection.  Final Result:  The reviewer determined that the requested medications 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 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

The parents of a 16-year-old male enrollee have requested for Genotropin growth hormone therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that there is no evidence to support continued growth hormone therapy for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the submitted documentation supports the services at issue in this clinical setting.  According to the medical literature, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  The medical literature noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluation.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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Urgent Care
Decision: Upheld

A 47-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that there was no new injury or sudden change in her condition that prompted her emergency visit. Her pain does not appear to have been severe, as she declined pain medication in the emergency department.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested for speech therapy for treatment of the enrollees receptive and expressive language delay. Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial.  Per Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. .  All told, the requested speech therapy 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 authorization and coverage for endoluminal ablation of varicose veins. Findings:  The physician reviewers found that the American College of Phlebology Guidelines support the use of endovenous thermal ablation in this clinical setting. There is also a body of evidence that supports the use of endovenous thermal ablation for the treatment of patients with symptomatic incompetence of the accessory great saphenous veins. The standard practice is to treat refluxing accessory (anterior) saphenous veins, which are in communication with the refluxing saphenofemoral junction, with ablation or by phlebectomy, if needed. In this patients case, the severity of her symptoms and the failure of conservative measures to treat her symptoms support treatment with endoluminal ablation. For these reasons, endoluminal ablation of varicose veins are likely to be of greater benefit than other standard modalities for the treatment of this patient. Final Result: 2 of 3 reviewers determined that the requested services are 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 vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.