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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira for treatment of her chronic hepatitis C virus genotype 1a.  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) 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. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. All told, the medical literature supports the requested Viekira Pak as medically necessary for treatment of this 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: All three reviewers are board certified in internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam therapy for treatment of her medical condition. Findings:  The physician reviewer found that the standard approach to treat breast cancer with a partial technique is to use a three-dimensional conformal or intensity modulated technique. When using protons to treat breast cancer there are concerns because the dose delivered to the skin is the full prescription dose which is higher than the skin dose with photon techniques. In this case, the clinical documentation submitted has not described an adequate clinical reason which would preclude the use of a standard partial breast technique. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of all stages of breast cancer. The National Comprehensive Cancer Network guidelines also state the standard for treating breast cancer is with conventional photon techniques. Therefore, proton beam therapy is not medically necessary in the treatment of the 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollee who has been diagnosed with malignant melanoma. Findings:  2/3 of the physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis for other than BRAF and c-KIT mutational analyses which are clinically useful only for patients with advanced disease considering these molecular targeted therapies. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, the gene testing would be considered investigational/experimental for this patient. Accordingly, the gene testing performed was not likely to have been more effective than the other options of evaluating this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were not likely to have been 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 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

The patient is a 13-year-old male with failing growth who has been denied authorization for growth hormone therapy. As of March 2006 the patients height was 134.1cm. A bone age study performed in February 2006 at the chronological age of 12 years 2 months revealed an estimated bone age of 11 years.  IGF-1 was 129. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.The patient has been dramatically falling off the percentile for height (50th to less than 3rd percentile), has been found to have a pathologically small pituitary gland, has had low levels of growth hormone dependent IGF-1 and IGFBP-3, and has been found negative for alternative explanations for his growth failure such as hypothyroidism, inflammatory bowel disease and celiac disease. As stated by the patients endocrinologist, provocative testing for GH levels would not contribute further to the diagnosis of GH deficiency. Growth hormone therapy is medically appropriate and indicated in this instance and should be authorized.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for Faslodex for treatment of her metastatic breast cancer.  Findings:  Two physician reviewers found that there is no benefit to concurrent chemotherapy with hormonal manipulation as compared to sequential therapy with these agents. In view of this, the use of concurrent chemotherapy with hormonal manipulation is no longer widely utilized by treating oncologists for the treatment of metastatic breast cancer. The standard of care is to use these treatments sequentially. There have been no studies which have explored the concurrent therapy with Faslodex/chemotherapy as compared to sequential therapy with these agents. This combination is not recommended by the National Comprehensive Cancer Network (NCCN) consensus panel recommendations and is not FDA approved or compendium listed.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested the medication Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has uncontrolled diabetes mellitus type 2. It is reasonable and medically necessary for the patient to be treated with Byetta in addition to metformin. As noted by Nathan and colleagues, Byetta is indicated for the treatment of diabetes mellitus type 2 in combination with metformin. This patients endocrinologist has made the medical decision to add Byetta to this patients regimen based on their doctor-patient interaction. There is evidence that this patient was receiving Byetta in 2008, so this appears to be a continuation of therapy.
Appeal type: Medical Necessity
Decision: Upheld

A parent/guardian of an enrollee has requested reimbursement for residential treatment center (RTC) services.  Findings:  The physician reviewer found that the records provided for review do not demonstrate the RTC services provided specific dates were medically necessary for treatment of this patients behavioral health condition. There was a lack of evidence that the patient had severe and persistent psychiatric symptoms that result in impairment requiring active treatment in a 24-hour supervised setting. There was no evidence of suicidal or homicidal ideations, no evidence of psychosis, and no evidence of physical aggression during this period of time. None of the medication changes made during this period of care required 24-hour supervision and treatment.  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: Upheld

A 45-year-old female enrollee has requested a total knee replacement for treatment of her knee pain.  Findings:  The physician reviewer found that the presence of obesity (BMI of 30 or above) as a risk factor in total knee arthroplasty has been long recognized. A higher infection rate is found in obese patients than in non-obese patients, and these patients also have an increased risk of implant failure. This problem is present both in the initial implant and also in revision surgery. The impairment of outcomes is present with evaluations of both early outcomes, and over time.  In this case, this patients most recent BMI was in the area of increased risk. This problem was identified by her treating physicians, and they recommended against a total knee arthroplasty. They did suggest continued efforts at weight reduction and conservative management. These measures may provide sufficient symptomatic improvement to avoid the necessity of surgery, but at the least would increase the possibility of success and also diminish the risks to the patient if replacement surgery were still needed.  All told, the requested total knee replacement of the right knee is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy.  The position statement from the American Society for Radiation Oncology (ASTRO) states that, the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO. The NCCN noted that photons with IMRT is considered the standard of care in this clinical setting. Researchers compared IMRT and proton therapy for localized prostate cancer. The authors found that patients treated with IMRT reported a lower rate of gastrointestinal morbidity than patients treated with proton beam radiation therapy. Researchers found no difference in toxicity between PBRT and IMRT in a cohort of patients with prostate cancer at 12 months post-treatment. This patient has prostate cancer without evidence of metastasis. Therefore, proton beam radiation therapy was not and is not medically necessary for treatment of this patient. 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 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: Overturned

The father of an eight-year-old male enrollee requested authorization and coverage of continued speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech and language disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a.  Two physician reviewers 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni. 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection.  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: All three reviewers are board certified in internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation therapy (TMS). TMS is a non-invasive, neurostimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. TMS does not have an indication for anxiety or chronic depression at this time. A study found the standard parameter set provided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The Clinical TMS Society recommends considering continuation or maintenance TMS therapy when other established methods of maintenance antidepressant therapy fail to provide a satisfactory sustained pattern of clinical benefit or a patient has a history of frequent relapse. However, according to the medical records, the patient was still symptomatic and far from remission with ongoing TMS therapy while the documentation did not establish the failure of standard interventions. Additionally, despite the severity of her illness burden, there was no mention of consideration for intermediate treatment settings, such as intensive outpatient services, partial hospitalization programming or residential placement. Finally, there was no discussion of the previous ECT trial, aside from its lack of efficacy. As ECT remains the proven non-pharmacologic intervention in the treatment of depression to which other stimulatory techniques are measured, a critical review of the prior course of treatment, and possible reconsideration of the modality, may have been appropriate.  In sum, TMS was not medically necessary for the treatment of this patient. 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 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 patient is an 18-year-old female who has a large right breast with significant ptosis and relative hyperplasia. The left breast, by photographic appearance, is small relative to the right breast, but it does not appear this is a case involving minimal development. The patients provider has recommended mastopexy of the right breast and augmentation of the left breast to achieve breast symmetry. The Health Plan indicates the requested surgery is not medically necessary. The Health Plan has recommended either augmentation of the left breast or reduction of the right breast for treatment of the patients breast asymmetry.The patient is requesting bilateral breast surgery to address the asymmetry in development. Neither of the patients breasts viewed alone could be described as congenitally abnormal. The issue is the asymmetry between the two breasts. Unilateral breast surgery in this patient is acceptable to achieve symmetry to the extent possible (either reduction of the right breast or augmentation of the left breast). Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy (3 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollees autism. Findings:  The physician reviewer found that although this patient has been participating in several hours of ABA therapy per week, he still presents with significant deficits. Such deficiencies are appropriately treated with speech and occupational therapy. He presently will be unable to participate in a formal school setting even with special education classes without the utilization of the proposed modalities. Given adequate evidence supporting the use of these therapies in the scientific studies and case series, speech therapy for 2 hours per week and occupational therapy utilizing sensory integration for 1 hour per week are medically necessary for management of this patients condition. It is crucial that the requested therapeutic interventions be individualized for the patient and tailored to address his specific deficits. This regimen should be continued for six months at which time each modality should be reassessed.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested laser therapy for the treatment of her degenerative disc disease and stenosis of the cervical spine. Findings:  Three physician reviewers found that the available medical literature does not support the use of laser therapy in this case. The available medical studies do not show the efficacy of this therapy over other available modalities or treatment. It is unclear how long the treatment benefits last or whether there is any practical carry-over or carry-over that can be applied towards activities of daily life (strength, range of motion, and pain-relief). Whatever local, temporary increase in blood circulation that laser therapy provides can be replicated with other, commonly used modalities such as ice, massage, and exercise. These modalities would also have the same effect (providing temporary relief) as laser treatments would on muscle pain and stiffness.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee requested authorization and coverage of a urology consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for treatment of the enrollees urinary tract infection.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee requested partial hospitalization program (PHP) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. This patient meets all seven Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for oppositional defiant disorder.  First-line treatment is therapy and for more severe conduct disorders such as physical aggression, approaches such as multidisciplinary and multimodal treatments are highly recommended, such as those provided in a partial hospitalization program.   During PHP days the patient began to show improvement in the areas of attentiveness, ability to relate to others, and requiring fewer staff prompts. Accordingly, the patient met the medical necessity criteria for continued stay in the partial hospitalization program.  First, his frequent violent physical outbursts represented an imminent risk of harm to others and to property.  Also, he had co-occurring behavioral health problems that could not be managed as manifested by the aforementioned. Finally, assessment and treatment planning required observation and interaction for at least 20 hours per week that included frequent interaction and observation, extended interaction in the program, requiring a structured environment to practice and enhance skills that will help the patient continue in his current living situation or return to school, requires the support of a structured environment to complete treatment goals and develop a plan for post discharge services in a less intensive setting. For the reasons provided, based upon the documentation submitted for review, the services at issue were medically necessary for treatment of the patients medical condition.