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

The parent of a five-year-old male enrollee has requested authorization and coverage for a speech evaluation and/or speech therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this five-year-old patient has significant behavioral problems, immaturity and unintelligible speech. He has received a limited amount of speech therapy in an early intervention school program. His speech therapist has recommended continued speech therapy and his provider, more than one year ago, recommended a speech evaluation and speech therapy, if indicated on evaluation. The Health Plan has denied speech evaluation and therapy based on the fact that the patients speech delay is neither acquired nor congenital. The patients symptoms are consistent with developmental aphasia, which is often congenital. Patients with developmental aphasias have abnormal brain development in regards to processing speech. This patient has been in a speech therapy program and his speech therapist states that he has made improvement, which indicates that his condition is treatable. The medical community has long recognized the value of speech therapy in children with developmental aphasia (Law, et al. and Goorhuis-Brower and Kniff). A speech evaluation and speech therapy are medically indicated for this patient. The medical community standard for a five-year-old unintelligibly speaking child is speech therapy.  The patient should receive a speech evaluation and at least one hour per week of individual speech therapy for six months, followed by speech re-evaluation. If the patient demonstrates improvement, but still has significant expressive speech dysfunction, speech therapy should be continued for another six months, at which time the patient should be reassessed.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a prescription of Lantus Solostar insulin pen for the treatment of his diabetes. Findings:  The physician reviewer found that insulin therapy is often essential for effective management of type 2 diabetes, as well as type 1 diabetes, and optimization of insulin therapy reduces the progression of diabetes and the development of diabetes-related complications (Kumar, et al).  Insulin pens have become increasingly available and have been associated with improved ease of use, user confidence, treatment satisfaction, and quality of life compared with vials and syringes. In this case, the Lantus Solostar insulin pen is indicated for this patient given that the pen is easier to use and may enable more precise dosing. In sum, the request for Lantus Solostar insulin pen is medically necessary for treatment of the 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 physician reviewer is board certified in endocrinology 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a fourteen year-old male who had gynecomastia has requested reimbursement for bilateral mastectomy.Reviewers Findings:The reviewing physician found that the procedure at issue was not medically necessary for treatment of the patients medical condition and that there were other methods to treat the condition.  The physician concluded that the health plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that breast 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, there are several factors to be considered.  Simply the presence of implants is not, in itself, an indication for tomosynthesis.  However, she had an area of asymmetry involving the left breast one year earlier.  The subsequent diagnostic study apparently did not reveal any areas of significant concern.  Considering that there was an area of asymmetry previously that was felt to be new when compared to the prior mammogram, however, warrants a close re-evaluation of this area.  It is not unreasonable to perform a tomosynthesis for a more thorough screening at this time.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers number one, two, and three are is board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication regimen Dupixent 300 mg/2 ml subcutaneous injection administered twice on day 1 (600 mg/4 ml) followed by once (300 mg/2 ml) every two weeks thereafter. This patient has a chronic history of moderate to severe atopic dermatitis and is requesting coverage for Dupixent. The records document that he has failed therapy with topical steroids and topical immunomodulators. Dupixent has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe atopic dermatitis in adolescents and adults.  This patient has a lifelong history of this condition. Given the chronicity and severity of disease in this patients case, the requested medication regimen is medically indicated. Therefore, the medication regimen Dupixent 300 mg/2 ml subcutaneous injection administered twice on day 1 (600 mg/4 ml) followed by once (300 mg/2 ml) every two weeks thereafter is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 dermatology 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

A 44-year-old male enrollee requested Sovaldi 400mg and ribavirin 200mg for 24 weeks for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Based upon the medical records, it is likely that this patient has cirrhosis with portal hypertension.  He has a nodular liver on MRI with splenomegaly.  In this case, FibroSure most likely underestimated the degree of fibrosis. This patient is likely to benefit from viral eradication.  Therefore, Sovaldi 400mg and ribavirin 200mg for 24 weeks are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Pylera for the treatment of H. pylori. Findings:  The physician reviewer found that patients who have failed clarithromycin regimens should not be retreated with those due to high risk of resistance and treatment failure. In this case, the patient has failed such a regimen, and another triple therapy regimen. Song and colleague have noted that Pylera has been effective after failure of clarithromycin-containing triple therapy, and in patients who had failure of 3 prior triple therapies including patients resistant to fluoroquinolones and metronidazole. Malfertheiner and colleagues found that the timing of drug administration for Pylera is simpler than use of the generic bismuth quadruple therapy, resulting in a compliance rate above 95%. For these reasons, Pylera has been FDA-approved for the treatment of H. pylori, and the generic alternatives have not. In this case, given the patients prior failure of multiple regimens, and the higher potential for compliance using Pylera, the requested medication is superior to the formulary alternatives. Accordingly, the medication Pylera is medically necessary for treatment of the 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 subspecialty 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

An enrollee has requested reimbursement for advanced lipoprotein testing. There is a lack of clinical studies demonstrating that addressing issues identified by novel lipoprotein testing analysis will further reduce a patients cardiovascular risk beyond standard analysis and treatment planning. Overall, clinical trial data do not support the superiority of treatment strategies incorporating non-statin lipid modifying agents compared with intensive or moderately intense statin therapy. Current guidelines support use of an LDL lowering statin therapy in this patient with an intermediate risk. Additional testing to determine whether the patient was not needed. Accordingly, the advanced lipoprotein testing was 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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 59-year-old female enrollee requested ondansetron (Zofran) 8mg, one tablet every six to eight hours, for medical treatment of her nausea and vomiting. Findings:  The physician reviewer found that the patient was treated for postoperative nausea with Zofran 8mg orally every six to eight hours.  Zofran 8mg is not approved for the treatment of postoperative nausea with vomiting.  The documentation does not support that the patient required the prescribed dosage of Zofran.  All told, Zofran 8mg, one tablet every six to eight hours was not medically indicated for the treatment of this patient
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether the perirectal spacers used during prostate radiotherapy that was performed were likely to have been more beneficial for treatment of the patients condition than any available standard therapy. The records indicate that the patient was diagnosed with malignant neoplasm of the prostate and adenocarcinoma. He underwent placement of a fiducial marker and absorbable perirectal implant for radiotherapy. Findings:  Three physician reviewers found that current published evidence in the peer-reviewed medical literature supports the use of perirectal spacers to improve health outcomes in patients with prostate cancer undergoing radiotherapy. In clinical trials, this benefit has translated into decreased long-term rectal toxicity, decreased urinary incontinence, and better sexual function. Overall quality of life was also better in patients who had the perirectal spacers placed during prostate radiotherapy. The National Comprehensive Cancer Network (NCCN) supports perirectal spacers in the national guidelines for the management of prostate cancer. Final Result: The reviewers determined that the perirectal spacers was 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 overturned.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.Findings: According to recent guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. A trial showed a 95% cure rate with eight weeks of treatment.  Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested extracorporeal shock wave treatment (ESWT) for treatment of her sesamoiditis.  Findings:  Three physician reviewers found that there is a lack of peer-reviewed, double-blind, placebo-controlled studies evaluating the efficacy of extracorporeal shock wave treatment for the treatment of this patients condition. Extracorporeal shock wave treatment has been FDA approved for the treatment of painful chronic proximal plantar fasciitis and lateral epicondylitis. While some efficacy has been demonstrated with this treatment modality, the efficacy of these services has not been demonstrated for the treatment of sesamoiditis.  Therefore, extracorporeal shock wave treatment is not likely to be superior over other available treatments in this patients case.
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.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Per the manufacturers prescribing information Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor, and is FDA-indicated for the treatment of chronic hepatitis C (CHC) genotype 1 infection in adults. In addition, Harvoni carries the highest American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendation of Class I, Level A for treatment of HCV patients. In this case, the medical necessity of HCV treatment as per AASLD/IDSA recommendations, and the medical appropriateness of therapy as proposed for this patient, exists 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).  In sum, Harvoni is medically necessary 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine, which includes neutral, flexion and extension. There is a lack of prospective, controlled, randomized studies that have shown the effectiveness and accuracy of upright MRI scanning versus the gold standard of MRI imaging. Small studies have reported promising findings to support the utility of upright MRI in limited circumstances. In this case, the patient presents with evidence of a 3 mm enhancing right-sided nerve root lesion at the level of L2 found on contrast enhanced MRI. This is an incidental finding that does not explain his symptoms and does not require further evaluation with the requested MRI. Given these findings, the requested MRI of the lumbar spine, which includes neutral, flexion and extension is not medically necessary for 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 neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for Lyrica 50mg capsules, once daily to help with fibromyalgia. The current guidelines do not recommend one therapy over another. A study found that the most extensive evidence is available for pharmacological treatment of neuropathic pain, and currently recommended first-line treatments include anti-depressants (tricyclic agents and serotonin-norephinephrine reuptake inhibitors (SNRI)) and anticonvulsants (gabapentin and pregabalin). Given the patients multiple co-morbidities, Lyrica is a reasonable choice to treat both her fibromyalgia pain and her neuropathic pain. Under these circumstances, Lyrica 50mg capsules, once daily, are medically necessary for treatment of the enrollees 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 subspecialty 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: A 57-year-old male with a history of osteoarthritis of the left knee requested authorization and coverage for hyaluronan injections for the left knee.A review of medical literature reveals mixed results. Researchers conducted a literature review to determine the strength of evidence in support of the efficacy of intra-articular hyaluronan acid (IAHA) injections from randomized controlled trials and meta-analyses. The analysis showed that IAHA provided a moderate symptomatic benefit to patients with knee osteoarthritis without major safety concerns. IAHA may offer one of the best benefit-to-risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. Researchers review of literature noted that meta-analysis of double-blinded sham controlled trials with at least 60 patients did not show clinically important differences of treatment with IAHA over placebo. Researchers noted that in a randomized double-blind comparison of treatments with IAHA and triamcinolone, IAHA increased functional scores but was not superior to the use of triamcinolone.  This patient has a history of osteoarthritis of the left knee, which has failed to improve despite treatment with arthroscopic surgery, bracing, intra-articular corticosteroid injections, low impact exercise and medications. In this case, the options are limited, and the purpose of current treatment is to relieve pain and postpone a total knee arthroplasty. As such, the requested hyaluronan injections for the left knee are medically necessary.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 orthopaedic 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.