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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. In addition, the utilization of tomosynthesis allows for better characterization of possible masses, spiculation, and architectural distortion.  Based on the support in the peer-reviewed literature, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Supartz FX 10 mg/mL intra-articular injections provided in each knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is an effective option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. This patient has experienced excellent relief with hyaluronic acid injections. Thus, the Supartz FX 10 mg/mL intra-articular injections provided in each knee medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested chemotherapy regimen consisting of Herceptin and sodium phenybutyrate in combination with Torisel for treatment of her ovarian cancer.   Findings:  Two physician reviewers found that use of Herceptin has not been extensively tested in ovarian cancer, and is not listed in the National Comprehensive Cancer Network (NCCN) practice guidelines as an evidence-supported treatment in this disease. Herceptin is known to be active in breast cancer, and likely other cancers, where the tumor expresses the HER2 antigen. In this patients case, immunohistochemical staining for HER2 of the primary tumor was not available in the provided records but the provider reports that the patients tumor overexpressed HER2. A Gynecologic Oncology Group (GOG) study noted that single agent Herceptin in HER2 expressing ovarian cancer was minimally effective with only a 7% response rate (Bookman, et al). However, in the GINECO phase II study, the similar patient population was treated with Herceptin combined with chemotherapy (Carboplatin/Taxol) and resulted in an impressive complete response in 4 of 7 patients, and stable disease in 2 additional patients (Ray-Coquard, et al). Thus, while use of Herceptin has been denied, given that this patients tumor overexpresses HER2, it is reasonable to allow coverage for use of Herceptin in combination with cytotoxic chemotherapy, as per the GINECO trial. Despite the likelihood that Herceptin will provide this patient a more beneficial outcome than standard therapies, there is still inadequate support for the effectiveness and safety of sodium phenylbutyrate in the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Actemra. Tumor necrosis factor (TNF) inhibitors are contraindicated for patients with lupus due to an increased risk of drug-induced lupus. Verden and colleagues note that the use of Janus kinase (JAK) inhibitors may increase the risk for thrombosis. In this case, the patient has diagnoses of systemic lupus and antiphospholipid syndrome, with a high risk for drug-induced lupus and thrombosis. She has tried and failed multiple medications including methotrexate and leflunomide. In this clinical setting, given that Actemra remains a viable option without an increased risk of drug-induced lupus or thrombosis, the requested medication is medically indicated. Therefore, Actemra is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for a bilateral mastectomy with reconstruction for treatment of the enrollees left breast infiltrating ductal carcinoma with metastases to lymph nodes. Findings:  The physician reviewer found that Breast cancer procedures have varied waiting times, generally because procedures must be scheduled into available operating room time, and longer procedures, those requiring coordination with other departments, and those involving coordination between surgeons may be more difficult to schedule. This is demonstrated by greater times for mastectomies, radionuclide use for sentinel node biopsy, and cases involving simultaneous reconstruction. Time-specific quality indicators for breast cancer have previously been developed. The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) endorsed three such criteria, namely the start of radiotherapy within one year of diagnosis, hormonal agent use within one year of diagnosis, and receipt of adjuvant chemotherapy within 120 days of diagnosis. The National Quality Forum has endorsed this last measure for women with hormone receptor-negative breast cancer based on an average of 30 days from initial diagnosis to completing surgery. However, outcome differences have not been noted in several studies evaluating delays in waiting times to surgery, chemotherapy administration up to 12 weeks, and radiotherapy up to 20 weeks. It is reasonable to wait seven additional days for the scheduled surgery based on the current medical literature and guidelines for the combined surgical procedure of bilateral mastectomy, complete axillary dissection, and immediate reconstruction with plastic surgery. The surgery is medically necessary, but the request to complete the surgery prior to */*/** is not medically necessary. 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 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

A female enrollee requested a 12 week course of Harvoni for medical treatment of her hepatitis C virus genotype 1.   Findings:  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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested treatment with Harvoni should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone HCL ER 10 mg, every eight hours for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The records indicate appropriate utilization of the requested medication. The patient has tried and failed multiple non-opioid medications and short-acting opioid medications.  He has demonstrated improved analgesia and function with the requested medication regimen.  There is no documented aberrant behavior or side effects.  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: Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested for Nexavar, administered as part of Protocol 06-03 for treatment of his metastatic melanoma.   Findings:  Two physician reviewers found that the clinical trial offered to this patient is well-designed and offers him chance of benefit. Bevacizumab is active in a wide variety of cancers and is promising in melanoma given the high levels of VEGF in this disease. Sorafenib (Nexavar) targets pathways implicated in melanoma. Oxaliplatin has been shown to be active with bevacizumab.
Appeal type: Urgent Care
Decision: Upheld

The parent of a two-year-old female enrollee has requested emergency services for treatment of her medical condition.  Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had been experiencing a cough for the past five or six days. She had no concurrent symptoms such as a fever or vomiting. Although she was pulling at her ears, on the night she was evaluated the patient did not appear to be in any distress. The physicians notes document that the patient was alert and animated. The patient did not require any pain control or any medications in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms do not meet criteria for an emergency medical condition. A prudent layperson in the parents circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 62-year-old female with a history of osteoarthritis of the right knee. The records noted a history of infection after a Synvisc injection for which arthroscopic debridement and intravenous antibiotics were utilized. Cultures from that procedure were negative. The patients current treatment includes Naproxen and cold packs. Corticosteroid injections have provided short-term relief. The provider has recommended viscosupplementation with Euflexxa for pain relief. The patient has requested coverage for Euflexxa injections. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. Current literature supports the use of viscosupplementation for osteoarthritis of the knees. According to researchers, intra-articular hyaluronic acid provides a moderate symptomatic benefit for patients with knee osteoarthritis.  Viscosupplementation may allow for substantial delay in time to total knee replacement. Medical evidence indicates that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting when compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The patient has knee osteoarthritis, and had short-term pain relief with corticosteroids.  Therefore, Euflexxa injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested injections are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old female enrollee has requested speech therapy for the treatment of the enrollees condition. Findings:  The physician reviewer found that speech therapy is, in fact, serving as treatment for this patients congenital condition. The enrollee's therapist has set forth expected goals and a plan to reach those goals. Whats presented here does fulfill the need for speech therapy as a medical necessity.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee requested authorization and coverage of a custom molded knee brace with polycentric joints. The Health Plan denied the request indicating that the requested equipment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  This patient is ineligible for the alternative regimens with ribavirin due to depression, which can be exacerbated by ribavirin.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male has requested coverage for physical therapy for treatment of his left hip pain.  Findings:  The physician reviewer found that leg length discrepancy is a controversial topic, especially with regard to the degree of discrepancy considered clinically significant (Gurney; and Brady, et al). Typical interventions include various orthoses or shoe modifications. Physical therapy (PT) may be warranted initially to functionally assess and address the condition, but there would not be expected to be an indefinitely recurring role for PT for this condition. Notably, in the present case, there is no clear documentation of any true leg length discrepancy. There seems to be a perceived discrepancy due to altered gait mechanics, possibly due to spasms, or some other muscular imbalance issue but this is unclear from the records provided for review. It is also not indicated what specific intervention is performed by formal PT that could not be independently performed with interventions such as stretching. Regarding the patients reported meralgia paresthetica, there is no clinical documentation related to the perceived cause of this condition. The primary intervention for this condition is assessing and addressing the cause of the condition, if possible (Harney and Patijn; and Patijn, et al). Empiric measures such as losing weight and avoiding belts are typical first-line interventions. Pharmacotherapy and local injections are second-line treatments. The role of PT for this condition, however, has not been established.Overall, there is no clear documentation of any pathological condition related to the hip or otherwise in the present case that currently requires formal, supervised, PT. There is minimal history provided, and no diagnosis other than hip pain. There were no documented measurements establishing a true or functional leg length discrepancy. PT was recommended for the hip pain, but no specific modalities or goals were identified. There were no PT notes indicating what interventions were being performed and why formal therapy interventions are needed on an indefinite basis. Thus, the records fail to establish the medical necessity of the requested PT for treatment of the patients hip pain.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee requested authorization and coverage of spinal fusion surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees back pain.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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for Afirma gene expression classifier for evaluation of his thyroid nodules. Findings:  Three physician reviewers found that there are multiple peer reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. In this patients case, the cytopathology of the thyroid nodule was consistent with FLUS. The medical literature indicates that the risk of malignancy is between 5 to 15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The 2015 American Thyroid Association's guidelines state that for nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. This patients nodule is hypoechoic and is enlarging, which are worrisome features. If the genetic test is suspicious, the risk of malignancy increases to 40%. The risk of malignancy decreases to less than 6% with benign findings by gene expression classifier (GEC). In this patients case, the result of the Afirma GEC was suspicious for malignancy. This information was important to determine whether to perform thyroidectomy or not and the extent of surgery, hemi-thyroidectomy versus total thyroidectomy. The test is in vitro, which confers minimal physical risk to the patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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.