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

Nature of Statutory Criteria/Case Summary: An enrollee has requested methadone for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, methadone is not medically necessary for treatment of the patients medical condition. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain associated with fibromyalgia is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. For the treatment of back pain, a study states that Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy. Similar findings are reflected in the report by another research study which states that Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic [low back pain] LBP. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP. There are a variety of anticonvulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. In addition, short-acting opiates are more likely to cause adverse outcomes. Therefore, the request for methadone 10 mg is not medically necessary for 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 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: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee requested authorization and coverage of acupuncture therapy. The Health Plan denied the request indicating that acupuncture is not medically necessary for treatment of the enrollees chronic back and neck pain.One acupuncture reviewer performed a medical necessity Independent Medical Review. The acupuncture reviewer upheld the Health Plans denial on the basis that the requested treatment is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak for treatment of his chronic hepatitis C virus genotype 1a.   Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested Viekira Pak is medically necessary for treatment of this patients hepatitis C virus infection.  Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found that to date, there is no evidence to suggest that proton therapy is superior to image-guided IMRT for prostate cancer. In Zietman and colleagues comparison of the two modalities, the authors found better bladder dose distributions with IMRT. The authors stated that, several authors have compared photon and PBT (proton beam therapy) dosimetry. While the techniques have varied (i.e. conventional, conformal, or intensity modulated), PBT generally can reduce the low (less than 30 Gy) and medium dose (less than 60-70 Gy) regions of the bladder and rectum. However, they also found that, Conventional PBT results in comparatively higher femoral head doses compared to photon therapy, whether conventional, conformal on intensity modulated is used. Ultimately, the authors concluded that, The outcome is similar to IMRT therapy with no clear advantage from clinical data for either technique either in disease control or prevention of late toxicity. Thus, based on the current data, proton therapy may be an option for prostate cancer but has inadequate support in the current literature demonstrating clear benefits over standard treatment with IMRT therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Ribasphere Ribapak for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. AASLD/IDSA provides the following justification for the above treatment recommendation: Sofosbuvir 400 mg daily was combined with weight-based ribavirin (RBV), 1000 mg to 1200 mg, to treat HCV genotype 2 treatment-naive patients across 3 clinical trials: FISSION, POSITRON, and VALENCE. The FISSION study randomized patients to daily pegylated interferon and ribavirin (800 mg) for 24 weeks or sofosbuvir plus daily weight-based ribavirin 1000 mg to 1200 mg. The sustained virological response (SVR) was higher (94%) in patients who received sofosbuvir plus ribavirin compared with those who received pegylated interferon and ribavirin (78%). Across all 3 trials, 201 of 214 (94%) patients with HCV genotype 2 achieved SVR with sofosbuvir plus ribavirin. This patients records do not support advanced fibrosis; however, the medical necessity of HCV treatment, as per AASLD/IDSA recommendations, exists regardless 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); this patients life expectancy exceeds this limit. For these reasons, the requested Sovaldi and Ribasphere Ribapak is medically necessary for the treatment of this patients hepatitis C virus.  Final Result: The reviewer 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 reviewer is board certified in internal medicine with sub-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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Orthovisc injection for treatment of her medical condition.   Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  This patient has had multiple injections, and with each injection and each exposure to the antigen, there is an increased risk of allergic response. There is also risk of iatrogenic infection being introduced into the joint during the process of injection.  Researchers performed a meta-analysis of the efficacy of viscosupplementation.  The authors noted that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects.  All told, the requested Orthovisc injection is not likely to be of greater benefit than other treatment options.   Final Result: Two reviewers determined that requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 21-year-old female with a prior history of bulimia and anorexia, difficulty with concentration, and severe mood vacillation in the direction of anger, who was referred for psychological evaluation and treatment. She was interviewed in November 2005 and was noted to have not responded to medications such as Topamax, Zoloft, Concerta, Strattera with Lexapro, Effexor, Prozac, and Paxil. The patient indicated there had been a prior response to Lexapro 10mg per day for a couple of years. The initial mental status exam revealed a neatly dressed, friendly, cooperative, and restless young woman.  The patient commented she was really self-deprecating and I think thats the primary source of the depression.  I feel like I get really angry at things but I dont express it so then I get depressed.  She was diagnosed with major depression with possible bipolar tendencies, ADHD, anorexia and bulimia nervosa.  SPECT (and CT) scans were employed to aid in diagnosis.  It was recommended that the patient restart Lexapro, 5-10mg per day, and begin Lamictal, Adderall XR, and Omega-3 fatty acids (fish oil).The patient has requested reimbursement for the cost of the SPECT (and CT) scans.  The Health Plan denied the request based on a determination that the diagnostic procedures were not medically necessary for diagnosis or treatment of the patients psychiatric condition.The patients history and clinical exam were sufficient to formulate a meaningful differential diagnosis and to establish an effective treatment plan.  Notably, her provider ultimately recommended Lexapro, which the patient herself had indicated was effective at the start of her evaluation.  In total, I find the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left hip revision surgery.The goal of total hip arthroplasty is to restore the normal biomechanics of the hip joint, which includes the normal offset of the greater trochanter. The second goal is preservation or restoration of leg length equality, which is achieved while maintaining stability of the prosthesis. In this case, errors in the limb length and the femoral offset affected patient satisfaction after surgery, including function, pain, and the quality of life. Accuracy of the leg length and the high or low offset can be improved by using computer-assisted planning or surgery and the more recently introduced EOS imaging system. Femoral anteversion also needs to be carefully maintained. Attention should be paid to varus and valgus alignment. The most common errors are limb lengthening and a decrease in hip offset. In this case, there was an increase in the offset. Per the literature, when this causes symptoms, the hip needs to be revised. The requested services are medically indicated for management of the painful total hip arthroplasty. Therefore, the requested left hip revision surgery is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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 an eight-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the proposed ABA therapy for the treatment of this patient with autism and intractable epilepsy is medically necessary based on overall evaluation of the literature. Even in the patients age group, plasticity in the developing brain still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including cognitive therapies (ABA) can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. Additionally, the notion that an MRI finding of nodular heterotopia is incompatible with brain plasticity is speculative and is not supported by peer-reviewed literature. While heterotopias are frequently associated with a phenotype of cognitive impairment and seizures, they are rarely so pervasive that no brain pathways are spared.
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.  Findings:  Two physician reviewers found that the current guidelines support the medical necessity of the requested medication in this clinical setting.  Harvoni has been demonstrated to be highly successful at treating hepatitis C virus among patient co-infected with HIV and hepatitis C, genotype 1.  Given that this patient is co-infected with HIV, he meets American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines as high priority for treatment.  All told, the requested medication Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: 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.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested a neuromuscular electrical stimulation knee brace (Kneehab XP Quadriceps Therapy System) for treatment of her post left knee surgery.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The mainstay of therapy following anterior cruciate ligament (ACL) reconstruction is physiotherapy with a focus on recovery of strength, range of motion and agility.  When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition.  If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion restored (Shelbourne and Klotz; Andersson et al).  There is no proven benefit of substituting or complementing therapy for this condition, including with concomitant conditions such as a post-partial meniscectomy knee, with a neuromuscular stimulation brace such as the Kneehab device in question. According to a review by Kim and colleagues, the authors noted that the effect of neuromuscular electrical stimulation `on functional performance and patient-oriented outcomes is inconclusive` for this condition. In a more recent systematic literature review, Kruse and colleagues concluded that such bracing `remains neither necessary nor beneficial.` The authors noted, moreover, that in general, `Although neuromuscular interventions are not likely to be harmful to patients, they are also not likely to yield large improvements in outcomes or help patients return to sports faster` (Kruse et al). Although there are small studies that further explore this treatment intervention, there remains a lack of sufficient clinical data to support the use of this intervention for this patients condition. Given that the patient had already achieved significant levels of strength and range of motion prior to the use of the device, there were no indications that there was any impairment that would have precluded ongoing exercise and therapy to further strengthen the leg and improve function of the knee. Thus, the services at issue were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  Currently, there is not enough published data to support DecisionDX-Melanoma test for its routine use in this clinical setting. More studies are required to determine the utility of the results from these tests. The DecisionDX-Melanoma assay examines the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. The patients provider sent a sample tissue to DecisionDX where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy determining the risk of metastasis in thin thickness melanomas like this patients; however, decision-making based on the results of the test is indeterminate at this time. There are no formal standard procedures or precautions that would be changed in light of the data. The treatment of this patient would not change based on the results from this test. Moreover, this test is not considered routine standard of care and is not currently recommended by the National Comprehensive Cancer Network (NCCN) guidelines. As such, the DecisionDX-Melanoma test was not likely to have provided a greater benefit over the established tests on outcomes for the evaluation this patients medical condition.   Final Result: All three reviewers have 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:  All three reviewers are board certified in dermatology 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

A 49-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of her obesity. Findings:  Three physician reviewers found that this patient meets criteria for weight loss surgery based on National Institutes of Health guidelines. While laparoscopic sleeve gastrectomy does not have as long of a track record as Roux-en-Y gastric bypass or adjustable gastric banding (Lap-band), five-year follow-up data is available and documents good results. Additionally, outcome studies of the Lap-band are starting to show poor results. Moreover, Roux-en-Y gastric bypass is associated with dumping syndrome whereas sleeve gastrectomy is not. As such, laparoscopic sleeve gastrectomy is a medically reasonable and appropriate option for this patient.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Entyvio infusion treatment (300 mg for a total of six visits given over 27 weeks) at a hospital based center. The hospital-associated infusion setting is not supported for medical reasons based on the provided documentation, except on 7/13/18. The medical documentation does not reflect that the patient has experienced a severe or life-threatening reaction with previous infusions of Entyvio (which she is stabilized on), or that she has a medical condition which renders her unstable, exceptionally complex, or otherwise unsafe for or unable to have Entyvio infusion at home or at an outpatient infusion facility.  Outpatient or home infusion of biologic medications such as Entyvio has been shown in medical literature to be safe and effective with appropriately-trained monitoring staff, and studies have shown high patient satisfaction with home infusion and outpatient infusion facilities.  However, an exception is warranted for the infusion date of 7/13/18, as the patient will not have the ability to make alternative arrangements, and a delay in Entyvio infusion can result in a loss of remission. For these reasons, Entyvio infusion treatment (300 mg for a total of six visits given over 27 weeks) at a hospital based center on 7/13/18 is medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 51-year-old male enrollee has requested authorization and coverage for the addition of a microprocessor-controlled knee-shin system, a replacement lithium battery and a battery charger to his lower extremity prosthesis. Reviewers' Findings:  Two of the three physician reviewers found that the requested microprocessor-controlled knee-shin system has not become the generally accepted prosthesis even for a patient who is high functioning. There has not been sufficient study of this prosthesis and it has not been proven to be functionally superior to a standard prosthesis. The microprocessor-controlled knee has not been shown to improve functional outcomes or to reduce disability as compared to a conventional prosthesis.