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

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for speech therapy once a week for treatment of the enrollees speech delay. Findings:  The physician reviewer found that in this patients case, the records show that she has severe deficits in speech and language skills, as well as pragmatic language skills. This is complicated by the potential diagnosis of selective mutism. According to the current standard of care, speech therapy is medically necessary and appropriate. This patient has made progress with weekly intervention and active parent support. Although decrease in individual therapy sessions to twice monthly was recommended, the documentation from April 2016 supports good progress with the current weekly therapy sessions and active parent participation. Ongoing weekly therapy is medically appropriate. A decrease in intervention may result in loss of progress and regression, negatively impacting her ability to effectively communicate her wants and needs and provide age appropriate peer interactions. The medical literature show that the sooner and more aggressively these deficits are targeted, the better chance the child has for developing adequate skills to function in the community. Final Result: The reviewer determined that 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 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 a targeted genomic sequence analysis test for evaluation of her non-small cell lung cancer.   Two physician reviewers found that a portion of the testing at issue was likely to be more effective for this patient than other available options. The treatment of non-small cell lung cancer is guided by not only the specifics of the histologic type, but also the presence or absence of certain key mutations. Among the mutations that have been validated to be important in decision making are epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutations. These two tests are available as individual tests and it is not necessary that these tests be done as part of a larger panel. Therefore, the genomic profiling for EGFR and ALK were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.   Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified 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: An enrollee has requested a 24-week course of Sovaldi, Daklinza and ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to medical guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines state that patients with liver transplant are highest priority for treatment. In genotype 3 patients who have had a liver transplant, therapy is recommended with Sovaldi, Daklinza, and ribavirin for 12 weeks. This is based on the ALLY-1 study, which showed a high cure rate in liver transplant patients. Additionally, because the patient has failed Sovaldi and ribavirin for 24 weeks, the guidelines recommend 24 weeks of Daklinza, Sovaldi, and ribavirin in this case. This is based on the ALLY-3 study, which demonstrated poor cure rates (only 71% in Sovaldi-experienced patients) after 12 weeks of therapy. The guidelines cite study data reporting that delay in treatment may result in decreased survival. For these reasons, the requested treatment with Daklinza, Sovaldi, and ribavirin for 24 weeks 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia during colonoscopy for evaluation of the enrollees colon screening. Findings:  The physician reviewer found that the patient does not meet the criteria for anesthesia services performed during the colonoscopy. Specifically, the patient does not have any medical issues that necessitate the use of monitored anesthesia care for routine, screening colonoscopy. There is no documented history of high dose chronic opioid or benzodiazepine use that would render the patient intolerant to standard sedatives. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom fabricated oral appliance. The records provided for review document that this patient has a history of symptomatic obstructive sleep apnea (OSA). The patient is noted to have mild-to-moderate OSA given her sleep study results revealing an apnea/hypopnea index (AHI) of 8.1 events per hour and a respiratory disturbance index (RDI) of 9.9 events per hour. The patients provider has recommended treatment with an oral appliance. The U.S. Food and Drug Administration (FDA) has approved oral mandibular advancement devices for the treatment of patients with mild-to-moderate OSA. In addition, the current medical literature supports the use of an oral mandibular advancement device for use in the treatment of this patients mild-to-moderate OSA in order to prevent potential sequelae of her condition. Given these findings, the requested custom fabricated oral appliance is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male has requested speech therapy services for the treatment of the enrollees autism.    Findings:  The physician reviewer found that autism is a disorder of communication, socialization and behavior and is long lasting.  The condition is generally not reversible. Although speech therapy is appropriate for this patients condition, it is not medically necessary. Such services should be delivered by the educational system as part of a comprehensive psycho-educational program.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing for evaluation of the enrollees thyroid cancer. Findings:  two of three physician reviewers found that The testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has metastatic medullary thyroid cancer that has been treated with multiple tyrosine kinase inhibitors as well as immunotherapy. The patient has exhausted available standard therapies. Next generation sequencing with FoundationOne can provide possible targets for which clinical trials may be available. Therefore, the FoundationOne gene testing provided was likely to be more beneficial for evaluation than available standard therapy to guide decision making.Final Result: The 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz XR. Findings: Guidelines for the treatment of rheumatoid arthritis state that compared to tumornecrosis factor inhibitor (TNFi) monotherapy, TNFi therapy has superior efficacy when used in combination with methotrexate, based on high quality evidence. The guidelines do not specify an order in choosing the next drug to be added to traditional diseasemodifying antirheumatic drug (DMARDs). Researchers found in comparing the efficacy of tofacitinib monotherapy, tofacitinib plus methotrexate, and adalimumab plus methotrexate, tofacitinib and methotrexate combination therapy was non-inferior to adalimumab and methotrexate combination therapy in the treatment of rheumatoid arthritis in patients with an inadequate response to methotrexate in this trial. In this case, the patient continued to have rheumatoid arthritis disease activity despite DMARD monotherapy with methotrexate. The provider added Xeljanz to methotrexate to optimize disease control. The records show that the patient achieved improved disease control using Xeljanz and methotrexate. Given the medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xeljanz XR is medically necessary 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that treatment with Harvoni is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. Moreover, according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Therefore, Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for AccuBoost for treatment of the enrollees breast cancer.Findings:  The physician reviewer found that found that this patient meets criteria for standard partial breast radiation. Standard techniques for partial breast radiation include external beam partial breast radiation, interstitial brachytherapy or balloon brachytherapy. There is a lack of phase 3 studies that have utilized the use of noninvasive image-guided brachytherapy.  The data examining the use of partial breast radiation has been with standard external beam radiation or invasive breast brachytherapy. Due to the lack of clinical data on the AccuBoost technique and uncertainties about its dosimetry, it is not likely to be more beneficial than standard techniques. Thus, AccuBoost (CPT codes 77770, 77771 and 77772) is not likely to be more effective than other treatment options. Final Result: Two of three physician 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 reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 28-year-old female enrollee has requested highly specialized surgical services for the treatment of her Barlows disease. Findings:  The physician reviewer found that the patient has severe mitral regurgitation secondary to Barlows disease. She will require complex repair with sliding annuloplasty. This can only be done by a specialist in mitral repair. The requested services are medically indicated and warranted for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Daklinza 60 mg tablets and Sovaldi 400 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that The American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) treatment guidelines specific to the patients circumstance, genotype 3, treatment-naive patients without cirrhosis recommends the following treatment regimen: Daily daclatasvir 60 mg plus sofosbuvir 400 mg for 12 weeks. While this patients records may not support advanced fibrosis, the AASLD/IDSA guidelines support the medical necessity and medical appropriateness of HCV treatment. Per the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The patients available record supports that her life expectancy exceeds this limit. 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: Physician reviewer number one 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

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 problem of evaluating dense breasts or suspicious calcifications is a major issue faced by interpreting providers. In addition to the dilemma of evaluating dense breasts, there is a question of whether tomosynthesis is warranted in the general population as a screening tool. Friedewald and colleagues reported that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. However, in this case, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies without dense tissue that could obscure an abnormality. Thus, the addition of three dimensional digital breast tomosynthesis was not 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 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 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: Experimental/Investigational
Decision: Overturned

The parent of a 14-year-old male enrollee has requested past and future coverage for oral irinotecan hydrochloride (Camptosar).  Findings:  Two physician reviewers found that  adrenocortical carcinoma is a rare and difficult cancer to treat. The ideal therapy is complete surgical resection as noted in the National Comprehensive Cancer Network (NCCN) treatment guidelines. The main approach to the tumor has been surgical but at some point the tumor was inoperable and the oncologists tried cisplatin, mitotane, etoposide, IMC-A112, but the tumor progressed. He was then tried on oral irinotecan (Camptosar) based on testing for in vitro chemotherapy sensitivity. When chemotherapy is needed the recommended initial treatment includes combination therapy that includes mitotane. This patient was treated with this chemotherapy without substantial response. The NCCN guidelines also recommend evaluation for possible radiation therapy. This patients records do not describe if radiation was discussed but suggests that the patients tumor is in locations that would not tolerate higher doses of radiation. The NCCN does not offer guidance on further chemotherapy, and due to the rarity of the disease, studies have to be performed as large international trials. This patients treating oncologists are currently using a dose and dosing schedule based on previous experience in a number of diseases including Ewings sarcoma. Irinotecan has reportedly been used in a Phase II trial published in 2010 with an alternative dosing schedule with good results for stabilizing recurrent disease. Consistent with the findings reported in the Phase II clinical trial, the novel use of more frequent dosing of the irinotecan that provided stability of disease in many of the patients studied is adequate support for the use of Camptosar in this patients care.