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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic active hepatitis C are eligible for treatment and should be treated regardless of fibrosis score. In this case, Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C genotype 1. In addition, Treatment with a once-daily, single-tablet regimen of ledipasvir and sofosbuvir resulted in high rates of sustained virologic response among patients with HCV genotype 1 infection who had not had a sustained virologic response to prior interferon-based treatment. As such, the medical necessity for Harvoni for 12 weeks has been established in this clinical setting. 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: An enrollee has requested authorization and coverage for Neulasta. The National Cancer Care Network (NCCN) v2.0 2018 guidelines provide criteria for use of myeloid growth factors (MGFs) in patients with cancer receiving chemotherapy. NCCN considers the type of cancer and type of treatment in its criteria, and stratifies by risk of febrile neutropenia into high (>20% risk), intermediate (10-20% risk) and low (< 10% risk.. Recommendations for use of myeloid growth factors in intermediate risk cancer types is further dependent on patient risk factors. These include patients who are 65 years or older, have persistent neutropenia, bone marrow involvement of tumor, recent surgery, liver dysfunction (bilirubin > 2.0), renal dysfunction (creatinine < 50) or prior chemotherapy or radiation therapy. If the patient has 1 or more of these risk factors, then MGFs are recommended.Based on NCCN criteria, this patient falls into the intermediate risk category with colorectal cancer on FOLFOX therapy. In addition, this patient has positive patient risk factors including prior chemotherapy and a prior episode of neutropenic infection. Based upon NCCN recommendation, an MGF is appropriate for this patient. At this time, the patient is receiving filgrastim. Filgrastim is an MGF, and is equally effective in this clinical setting as the requested Neulasta. The only difference between Neulasta and filgrastim is the frequency with which the drugs must be taken  the former is administered once every two weeks, while the latter requires daily dosing. While the less frequent dosing might make Neulasta more convenient than the prescribed filgrastim, it cannot be said that Neulasta is more appropriate for this patient. Therefore, Neulasta is not medically necessary for treatment of this patients condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with a subspecialty certificate 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:  An enrollee requested Xiaflex for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The patient is unlikely to experience resolution of the penile curvature without treatment.  He has failed other treatments.  The current medical evidence supports the requested medication in this clinical setting.  In this patients case, there is a lack of viable alternatives except a surgical procedure with uncertain outcome.  This condition causes significant impact on well-being and quality of life.  Xiaflex is standard of care for the treatment of this patient.  All told, Xiaflex 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 urology 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

A 53-year-old female enrollee requested a subcutaneous implantable defibrillator (S-ICD) for medical treatment of the enrollees long QT syndrome (LQTS).  Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available options. Patients with LQTS are considered high-risk when associated with a family history of sudden death. In this case, the patient presents with LQTS type 5 and a strong family history of sudden cardiac death in three generations. Subcutaneous defibrillators have been shown to be effective in terminating induced and spontaneous ventricular arrhythmia and are U.S. Food and Drug Administration (FDA) approved. Therefore, the requested S-ICD is likely to be more beneficial for her medical condition than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for blood diagnostic test, Prometheus Anser ADA, provided.  Findings:  The physician reviewer found that  nn this patients case, Anser ADA was ordered to direct the management of the patients Crohns disease. However, the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with Humira (adalimumab) may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. A study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. A review article reported that the available data do not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab, and another concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response . Therefore, the clinical literature does not support that the blood diagnostic test, Prometheus Anser ADA, provided on the disputed  date was likely to have been more beneficial for evaluation of this patients medical condition than the available standard treatment options. Final Result: The  2 of 3 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 reviewers 1,2 & 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

A 60-year-old female enrollee has requested laboratory testing for coronary heart disease risk assessment for evaluation of her cardiovascular risk factors. Findings:  The physician reviewer found that guidelines for diagnosis and management of dyslipidemia as it relates to coronary risk have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests, such as the testing in this patients case, in the context of assessing coronary risk. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard clinical risk factor profiling coupled with basic lipid analysis.  Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.   Likewise, even though elevated lipoprotein(a) and certain LDL subclasses may be considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained elevated levels of these specialized tests in patients with or without known coronary disease.  All told, in this patients case, laboratory testing for coronary heart disease risk assessment performed on on the dates in question was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 11 hours of psychological testing. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested services in this clinical setting. The diagnoses of OCD, PTSD, major depressive disorder, and ADHD do not require psychological testing. They can be determined in the office via clinical interview with the assistance of scales such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Beck Depression Inventory, Beck Anxiety Inventory, and applying Diagnostic and Statistical Manual of Mental Disorders V criteria. The records do not indicate that these have been performed with this patient. The mental status examination is a tool used to assess cognitive function, and there was no indication that the patient suffered from an organic cause of his impulsive, attentional, depressive, obsessional, or suicidal thinking.  It is important to note that the patient was not seen in psychiatric consultation and was not on any psychotropic medications, which may have drastically altered the subjective symptoms reported, the behavioral manifestations, and objective findings by the provider.  Therefore, the request for authorization and coverage of 11 hours of psychological testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 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 61-year-old male enrollee requested authorization and coverage of intensity modulated radiation therapy (IMRT) for the treatment of prostate cancer.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for apolipoprotein test (CPT 82172). The records provided for review document that this patient has a history of elevated lipoprotein levels. The patients provider has recommended additional evaluation with apolipoprotein testing. However, there is a paucity of support for the requested apolipoprotein testing for further evaluation of this patients cardiovascular risk. The available medical literature has not shown that strategies to correct the residual risk potentially identified by apolipoprotein testing will further reduce a patients cardiovascular risk (Robinson). Current clinical trial data do not support the superiority of treatment strategies based on novel apolipoprotein testing as requested for use in this patients evaluation and treatment. Therefore, the requested apolipoprotein test (CPT 82172) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested apolipoprotein test (CPT 82172) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female has requested osteopathic manipulation for the treatment of her heel pain. Findings:  The physician reviewer found that the requested therapy is not medically necessary for treatment of the enrollees condition. There are no Class-1, peer-reviewed data demonstrating that the requested therapy has been proved to be beneficial in systematic reviews of randomized, controlled-trials or from individual, randomized, controlled-trials to support its use in the treatment of heel pain.  Furthermore, there are no studies that have demonstrated the efficacy of this therapy for the treatment of heel pain.  It is not within the standard of care for treatment of heel pain, or part of any published guidelines regarding the treatment of heel pain.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for signal-averaged electrocardiography (SAECG) for evaluation of her heart palpitations.   Findings:  Three physician reviewers found that the use of signal-averaged ECG has essentially been eliminated from clinical practice for the stratification of arrhythmia risk. There may still be some usefulness of this technique in experimental subsets of patients with prior infarction. However, the data have been unsupportive of its general use, even in this subset.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has speech therapy twice per week for the treatment of the enrollees speech impairment. Findings:  The physician reviewer found that the long-term consequences of inadequate treatment may be far-reaching and substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. They wrote that, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. The authors concluded that their study, shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The literature is supportive of the use of speech therapy for articulation/phonological deficits. In this case, the patient has a moderately impaired orofacial myofunctional level with swallowing difficulties. As such, speech therapy is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested selective internal radiation therapy (SIRT) for the treatment of her neuroendocrine cancer with liver metastases. Findings:  Three physician reviewers found that this patient presented with neuroendocrine tumor metastatic to the liver. There is no effective chemotherapy for metastatic disease to the liver. This patient is not a surgical candidate for surgical resection of tumor in the liver. There is adequate literature support for SIRT for liver metastasis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) treatment provided from 3/14/16 through 4/8/16. Findings:  The physician reviewer found that upon presentation, the patient identified significant anxiety and depressive symptoms. It appeared that bereavement contributed to, if not fueled, this patients acute-on-chronic symptom complex. However, she had no suicidal ideation. There was no report of psychosis, aggressive behavior or prior treatment in a more restrictive level of care. There was no psychiatric evaluation or mental status examination. She had a supportive family.  She had a strong faith-based system. She had safe housing. She had many activities of interest. She was well-educated and had no substance use history.  In sum, the patient was not experiencing an acute psychiatric syndrome and her prognosis was good. However, the patient had failed treatment in the outpatient setting. Thus, a higher level of care at the time was reasonably expected to improve the patients condition and prevent a more serious episode of illness at the time. Considering the relevant variables, an intensive outpatient program (IOP) would have been safe and appropriate. 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 physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested prospective authorization and coverage for residential treatment center services. Findings: The physician reviewer found that the Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the residential treatment center services were not and are not medically necessary for treatment of the patients behavioral health conditions. The documentation submitted for review does not support residential placement. The patient does not have significant post-acute withdrawal symptoms. His last use of substances was 10 days prior to admission. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was motivated and recognized the need for help. He was medically and psychiatrically stable. He had support systems in place. The structured, 24-hour setting of residential treatment was not and is not medically necessary in this clinical setting. The patient could have been treated at a lower level of care. Thus, the residential treatment center services provided from were not and are not medically necessary.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 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 authorization and coverage for Forteo injection 20 mcg for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that There is support in the medical literature for the requested medication in this clinical setting. The Fracture Risk Assessment Tool (FRAX) guidelines state the following, Teriparatide (Forteo) is an anabolic agent that stimulates bone formation and has been approved by the [U.S. Food and Drug Administration] FDA for treatment of osteoporosis. There are many studies in the medical literature that support the use of teriparatide to stimulate healing in nonunions, like in this patients case.  The literature is vast in favor of the positive effects of teriparatide and osteoporotic fracture healing and nonunion or delayed union healing of bone after surgery. In this case, the prescribed trial of Forteo for this patient with a high risk for fracture and a nonunion ankle bone fusion, is medically necessary. The patient had the initial ankle fusion procedure in 2015 with failure to heal. The patient had a revision in 2016 that also failed to demonstrate healing. Computed tomography scan has demonstrated only 5% bridging, and the patient is not responding to bone stimulation therapy. The patient is at high risk for hip fracture and according to the FRAX calculation, therapy for osteoporosis is indicated. Additionally, the patient has reported that the patient is in pain. Based on the evidence in the literature about the benefits of bone formation and fracture and nonunion healing, there is sufficient evidence to use Forteo for the purposes of stimulating bone formation, bridging and healing of the failed fusion, as well as to decrease the patients risk of hip fracture. For all these reasons, Forteo is medically necessary for the treatment of this patients medical condition. )Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.