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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Concerta for treatment of his behavioral health condition. Findings:  The physician reviewer found that there is no contraindication to the use of methylphenidate for reasons of cardiac disease or an eating disorder. In regards to concern about methylphenidate lowering the seizure threshold in this patient, the use of this combination is supported by expert opinion. The literature indicates that methylphenidate (MPH) is one of the most commonly prescribed medications to treat attention deficit hyperactivity disorder (ADHD). The literature further states Case reports have warned about new-onset seizures in patients treated with MPH, and drug-drug interactions between MPH and antiepileptic drugs as well as antidepressants. However, retrospective chart reviews, open-label trials and controlled trials of MPH in patients with epilepsy and ADHD have noted significant improvements in ADHD symptoms without an exacerbation of seizures or an adverse effect on antiepileptic drugs (AED) serum levels. Researchers also concluded children with epilepsy have a significant risk for problems with ADHD.  Clinical studies suggest a prevalence of 30% to 40%.  Inattention is more common than hyperactivity and impulsivity and treatment should include psychoeducational interventions and medication.  Stimulant drugs are safe and effective in children with epilepsy and currently are first-line agents for treatment of attention problems in this population.  Given the support above, the request for Concerta is clinically 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for automated whole breast ultrasound. A peer-reviewed medical literature states that automated whole breast ultrasound is US Food and Drug Administration (FDA) approved for use in screening for breast cancer as an adjunct to mammography. Consistent with this recommendation, the bulk of available data favoring a clinical role for automated whole breast ultrasound supports its use with mammography, not as a replacement for mammography. This is due to the limitation on automated whole breast ultrasound in the detection of microcalcifications and evaluating the deeper portions of the breast. This patient underwent evaluation with an automated whole breast ultrasound in 2017 which did not detect any abnormality other than dense breasts. The providers recommendation at that time was to consider tomosynthesis as a supplemental study to screen for breast cancer in this patient with dense breasts. In conclusion, automated whole breast sonography is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that automated whole breast sonography is 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 requested service is 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 diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the right knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of good relief from prior viscosupplementation in the past two to three years. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested services are medically necessary. Therefore, Orthovisc injections in the right knee are medically necessary for the treatment of this patient.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Three physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. This patients prior biopsy and family history of breast cancer are not, in themselves, an indication for tomosynthesis. However, she has breasts that have been described as being heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically the 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, in this clinical setting, the use of the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 Harvoni 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.  The guidelines recommend that 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, Harvoni 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 45-year-old male enrollee has requested Cialis for treatment of his erectile dysfunction.   Findings:  The physician reviewer found that based on review of the available records, this patient has erectile dysfunction due to cardiovascular disease. Cardiovascular disease is a common medical cause for erectile dysfunction. Treatment with a phosphodiesterase type 5 inhibitor such as Cialis, Viagra, or Levitra is appropriate and indicated. However, there is no documentation in the records provided for review that suggests the patient has tried and failed, or been unable to tolerate Levitra, which is approved by the Health Plan. Thus, the requested Cialis is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic treatment for treatment of levoscoliosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records indicate that this patient has received chiropractic care as maintenance therapy. Despite the patients report that he has new injuries, there is no documentation of any new injuries in his chiropractic notes. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature, and the treatment is considered maintenance therapy. All told, the requested chiropractic treatment is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in chiropractic care 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 16-year-old male enrollee has requested removal of a cyst for treatment of the enrollees epidermal inclusion cyst. Findings:  The physician reviewer found that the submitted medical records document an increase in the size of the cyst. The medical records noted that the cyst was 2 x 2 mm. A few months later, the cyst measured 6 x 6 mm.  The only effective, definitive treatment for epidermal inclusion cysts is surgical excision(Pandya and Radke).  The patient was experiencing associated symptoms, namely, an increase in the size of the lesion.  Thus, the removal of the cyst was indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for acute inpatient spinal cord rehabilitation. The complexity of the patients nursing, medical and rehabilitation needs supports an indication for acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. A review of the literature reveals that the provider directing the rehabilitation program of spinal cord injury patients must be skilled at performing neurological assessment of the patient and possess the knowledge to accurately predict the likely neurologic and functional outcomes based on this assessment. The provider can then direct an appropriate multidisciplinary treatment plan that will address the medical, functional, psychosocial, vocational, and avocational needs of the patient. This patients medical and rehabilitation needs require the services of a specialized spinal cord injury facility to ensure proper monitoring and teaching and prevention of complications that accompany this type of traumatic injury. Given these findings, the requested acute inpatient spinal cord rehabilitation is medically necessary for treatment of this patient. 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his rectal cancer. Findings:  Two physician reviewers found that in this patients case, 3D conformal radiation therapy is the currently accepted standard of care.  Given the relatively low dose of radiation in a preoperative setting, and given that this dose is well within the dose constraints of normal surrounding tissue, intensity modulated radiation therapy is not indicated.  The National Comprehensive Cancer Network guidelines do not support intensity modulated radiation therapy in this patients case.  The superior efficacy of intensity modulated radiation therapy in this clinical setting has not been established. All told, intensity modulated radiation therapy is not likely to be more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The Health Plan has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees knee pain.Nationally recognized evidence based medical guidelines recommend MRI of the knee for patients with acute trauma to the knee or if suspected posterior knee dislocation or ligament or cartilage disruption. For children or adolescents with nontraumatic knee pain, MRI is the next study after nondiagnostic radiographs, if internal derangement is suspected. Medical literature  reported an increasing number of individuals between the ages of 5-18 with a corresponding increase of acute and chronic injuries. MRI was recommended in this pediatric population because of its lack of ionizing radiation and assessment of the physis, apophysis, and adjacent soft tissues.  In this patients case, the records document a persistent right knee pain, intermittent swelling, and a marked limp. The patient has been unable to successfully participate in sports activities. Conservative treatment has included at least four months of activity modification, icing, nonsteroidal anti-inflammatory drugs (NSAIDs), and observation without improvement in symptoms. An initial x-ray was reported within normal limits. Clinical examination findings have been reported consistent with possible meniscus tear. As such, current evidence based medical guidelines and the medical literature support the use of MRI in this clinical setting to rule out internal derangement. Therefore, the requested MRI has been demonstrated as medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks and possibly up to 24 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that the medical necessity for treatment with sofosbuvir (Sovaldi) and daclatasvir (Daklinza) has not been demonstrated in this patients case. First, the proposed regimen is not FDA-approved for the patients indication, whereas the sofosbuvir and ribavirin regimen is both FDA-approved and carries a higher the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) rating. Moreover, the patient has not demonstrated intolerance to ribavirin. Per FDA labeling, sofosbuvir and ribavirin can be safely used in the patients situation if fertility is avoided during and for six months after his treatment course (a duration no longer than 10 months). For the reasons provided, Sovaldi and Daklinza for 12 weeks and possibly up to 24 weeks is not medically necessary in this clinical setting.  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 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:  An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that while this patients records do not support advanced fibrosis, the medical necessity of HCV treatment, as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations, and the medical appropriateness of therapy, exist irrespective of fibrosis score.  AASLD/IDSA guidelines, underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). This patients life expectancy exceeds this limit. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. For these reasons, the requested medication 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that, according to the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient would need to have a score of 23-28 in order to require treatment in an RTC. It appears that the patient had stabilized sufficiently to allow transition to a less restrictive setting.   Dialectical behavioral therapy (DBT) on an outpatient basis has been proven to be beneficial in reducing mood symptoms, emotional dysregulation and suicidal behavior in adolescents. Final Result: The reviewer determined that the services at issue were not and 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 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.