Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that performance of three dimensional breast imaging in this patient was indicated since the medical literature has been demonstrated that the sensitivity and specificity of three dimensional breast imaging is superior to two dimensional imaging alone for the detection of occult, non-palpable breast cancer. Three dimensional tomosynthesis allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. All told, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has requested authorization and coverage for right-sided minimally invasive sacroiliac (SI) joint fusion with triangular implants (iFuse procedure). SI joint degeneration is a common cause of chronic low back pain. Minimally invasive fusion procedures have demonstrated successful relief for patients with chronic low back pain who have failed conservative treatment. Among these implants, the triangular titanium implants such as iFuse, have been established in the medical literature to be safe and effective. Recent studies have documented two-year follow-up of these procedures can result in meaningful clinical improvement, maintained pain relief, and evidence of a solid fusion on imaging studies. Colleagues reported on long-term results from a prospective multicenter clinical trial. In this study, patients with SI joint dysfunction underwent minimally invasive SI joint fusion using triangular titanium implants. The authors found that treated patients showed marked improvements in pain, disability, and quality of life at two years. This patients records document the presence of chronic low back pain that has not responded to standard conservative measures. The patient has no evidence of neural compression on MRI, yet there are clinical findings of SI pain, which is relieved by injecting the SI joint. Given these findings, the requested right-sided minimally invasive SI joint fusion with triangular implants (iFuse procedure) is likely to be of greater benefit for the medical condition of this individual than any other standard treatment.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral screening digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Three 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, her breast tissue was described as heterogeneously dense.  It is specifically those 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, bilateral screening digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three reviewers determined that the service 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

A 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of surgical and psychological evaluations.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee has requested lamotrigine 100mg, Trazodone (1/2 tablet of lowest dose), venlafaxine 300mg, Topamax 25mg, and Lithium 300mg for the treatment of her severe depression and bipolar disorder. Findings:  The physician reviewer found that the requested doses of lamotrigine, venlafaxine, Topamax and Lithium are medically necessary for this patient. This conclusion is supported by the observation and testing of the patients hypomanic symptoms which lasted four to five days. The patient is being treated by a non-plan provider who made a diagnosis of bipolar affective disorder, which differs from the diagnosis of her previous provider. Treatment of bipolar affective disorder consists of mood stabilizers and it is not infrequent that patients may need a combination of mood stabilizers to enhance efficacy or reduce side effects. Based on the non-plan providers treatment notes, the patient does require a combination of Lithium, lamotrigine, and Topamax for maximum efficacy (in addition to venlafaxine). Many patients with bipolar affective disorder who are in the depressed phase benefit from a short-term course of antidepressant medications under the cover of mood stabilizer to prevent switching to manic/hypomanic phase. Accordingly, I find that Lithium, lamotrigine, venlafaxine and Topamax are medically necessary for this patient. However, the patient does not meet medical necessity criteria for Trazodone. There is no documentation in the submitted medical records that provide a clinical rationale for the use of Trazodone other than for purposes of sleep induction. Thus, the medical necessity of Trazodone is not established based on the evidence provided.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male has requested bilateral hip arthroscopy performed in a single surgery to correct bilateral femoroacetabular impingement for treatment of his hip pain.  Findings:  The physician reviewer found that the surgical treatment of femoroacetabular impingement has become more widely accepted despite the lack of high quality evidence demonstrating its efficacy. With regard to whether the performance of bilateral hip arthroscopies during a single operative session is medically necessary compared to staged procedures, the evidence is sparse and for the most part anecdotal. One recent paper indicates the intra-operative complication rate was no different than in staged procedures, and the outcome was no different in the near-term (Mei-Dan, et al.). Results over the longer-term are not yet available.  At this time, there is no peer-reviewed evidence demonstrating that the performance of bilateral hip arthroscopies during a single operative intervention is superior to staged procedures in terms of outcome, rehabilitation or complications. As such, the medical necessity of the proposed services for treatment of this patients bilateral femoroacetabular impingement has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for DecisionDx-UM testing.Findings:  Three physician reviewers found that local treatment for primary uveal melanoma is effective in preventing local recurrence in over 95 percent of cases, yet up to 50 percent of patients are at risk for metastatic disease. The high risk of metastatic disease is thought to be due to a propensity for early micrometastasis followed by a variable latency period prior to the emergence of overt metastatic disease. Gene expression profiling has been shown to be superior to chromosomal markers, as well as clinical and histopathological prognostic factors, for defining groups at high risk for the development of metastatic disease. Using primary uveal melanoma samples obtained by fine needle biopsy, gene expression profiling classifies tumors as having low (class 1) or high (class 2) metastatic potential. The risk of metastasis guides surveillance. DecisionDx-UM testing is considered a standard of care in this clinical setting. In sum, DecisionDx-UM testing was likely to have been more efficacious than other methods of evaluating this patient. Final Result: The 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 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the chest for evaluation of the enrollees chest pain. Findings: The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. According to the medical literature, a recent chest x-ray and a nuclear medicine bone scan are necessary tests to perform prior to evaluation with chest MRI in the evaluation of chest wall pain. The medical records indicate a chest x-ray was performed in January 2016 and that a bone scan has not been performed. For the reasons provided, the requested MRI of the chest is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewers determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number two is board certified in diagnostic radiology 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 Mavyret 100-40 mg three tablets daily for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. 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. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg three tablets daily 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: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested Aciphex for treatment of her chronic gastritis. Findings:  The physician reviewer found that Nexium is the S-isomer of omeprazole. Based on the records provided, the patient developed an allergic reaction to Nexium. Not only is omeprazole not indicated for this patient, she should avoid any related compounds. Omeprazole is a related compound to Nexium, and is in fact very similar. Therefore, it is contraindicated to give omeprazole to this patient since a rechallenge may cause a very severe reaction with potentially life-threatening consequences. The patient has been taking Aciphex with benefit and without untoward side effects. It is medically appropriate for the patient to remain on Aciphex and avoid taking omeprezole, Nexium and Prevacid.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested participation in a clinical trial, echocardiogram and pulmonary function test, for the treatment of her recurrent metastatic cancer. Findings:  Three physician reviewers found that there is a lack of data to support the efficacy of high dose chemotherapy in the management of metastatic breast cancer. No survival advantage has been demonstrated. Furthermore, the therapy is associated with increased toxicity. Review of the scientific literature reveals that investigations of high dose chemotherapy in this setting showed no better results than standard therapies. In light of the absence of supporting data, the proposed clinical trial is not likely to be superior to standard regimens.
Appeal type: Medical Necessity
Decision: Upheld

A patient has requested authorization and coverage for Praluent pen 75 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients hyperlipidemia. The submitted documentation does not support the medical necessity of the requested medication. The records indicate that this patient has hyperlipidemia with prior tolerance to both atorvastatin and ezetimibe with good results. Praluent is a proprotein convertase subtilisin/kexin type 9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol. The documentation provided does not sufficiently support that either of these categories are present or that the patient cannot tolerate atorvastatin and ezetimibe to treat the patients hyperlipidemia. Therefore, the requested Praluent pen 75 mg is not medically necessary for the treatment of this patient. 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 in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom foot orthotics. The Health Plan denied the request and reported the requested orthotics are not medically necessary for the treatment of this patient. At issue in this case is whether custom foot orthotics are medically necessary for the treatment of the patients medical condition. Plantar fasciitis is diagnosed based on the patients history and examination. The initial treatment is conservative, focusing on alleviation and resolution of the foot pain. Initial treatment modalities include taping, icing, proper footwear, stretching, and rest. The recommended orthotics with the additional application pads represent specialized applications to help alleviate foot pain. The requested orthotics include a metatarsal bar, an outflare wedge, a heel stabilizer, and heel depression for a calcaneal spur. Orthotics with these types of applications have been used as the standard of care conservative treatments for patients with plantar fasciitis and pes planus. The requested orthotics alter the biomechanics of the foot, allowing for pain-free range of motion and ambulation. In this case, the patient was diagnosed with congenital pes planus bilaterally, plantar fasciitis, and right foot pain. The patients current orthotics are worn, and he reported bilateral heel pain. The medical evidence supports the requested orthotics in this clinical setting. Therefore, custom foot orthotics are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested devices 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 podiatry 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 patient has requested authorization and coverage for a follow-up visit with a bariatric surgeon. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients morbid obesity with associated co-morbidities. The submitted documentation supports the medical necessity of the requested services. Bariatric surgery includes a variety of procedures performed on people who have been diagnosed with morbid obesity. Bariatric surgery has been shown to promote significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a significant decline in mortality. Studies have demonstrated that the success of bariatric surgery is dependent to a large degree with adherence to follow-up care. For this reason, the American Society of Medical and Bariatric Surgery has stated in their guidelines that patients who have undergone bariatric surgery should have close follow-up care. Therefore, a follow-up visit with a bariatric surgeon is 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 24-week course of Sovaldi and ribavirin for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  The American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The initiation of treatment for patients with early-stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications of hepatitis C.  All told, the requested 24-week course of Sovaldi and ribavirin is medically indicated for the treatment of this patient.  Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The 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.