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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for high intensity focused ultrasound (HIFU). Findings: HIFU therapy for low-grade, low-stage multifocal lesions, such as those present in this enrollee, necessitate treatment of the hemi-gland. Current literature recognizes the complexity of treatment decisions in the setting of prostate cancer. Some lesions that are Gleason 3+3 may harbor micro-foci of higher grade cancer, and treatment is warranted in young patients as active surveillance and associated repeat biopsy are not acceptable management. Treatment with radiation and prostatectomy is also not standard with a 3+3 tumor. A study reports that short-term results of hemi-gland HIFU indicate safety, excellent potency and continence preservation, and adequate short-term prostate cancer control. Long-term efficacy was not a primary endpoint of this study. In addition, another study reports that early evidence from their meta-analysis suggests that HIFU may result in some improved outcomes over prostatectomy. However, the authors note that at the time of their study, there have been no prospective randomized-controlled trials actually comparing the outcomes of radical prostatectomy, radiation therapy, and HIFU and that these trials are needed to investigate the benefits of HIFU for prostate cancer. Given the lack of evidence in current medical literature on the long-term efficacy of HIFU, the requested service is not medically indicated. Therefore, HIFU is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested authorization and coverage of the medication Vioxx. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees degenerative disc disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Lyrica 75mg capsules. Current nationally recognized evidence based medical guidelines recommend anti-epilepsy drugs (AEDs) for neuropathic pain. AEDs are recommended on a trial basis as a first-line therapy for painful polyneuropathy. Pregabalin (Lyrica) has been documented to be effective in the treatment of diabetic neuropathy and post-herpetic neuralgia. Lyrica has Food and Drug Administration (FDA) approval for diabetic neuropathy and post-herpetic neuralgia. It is considered a first-line treatment for both. Researchers concluded that clinical trial evidence supported the use of only gabapentin and pregabalin in some neuropathic pain conditions (painful diabetic neuropathy, post-herpetic neuralgia, and central neuropathic pain) and fibromyalgia. For other antiepileptic drugs there was no evidence, insufficient evidence, or evidence of a lack of effect. Under consideration is a request for Lyrica 75 mg. Current evidence based medical guidelines and peer-reviewed literature supports the use of anti-epilepsy drugs as first line treatment for neuropathic pain, including both gabapentin and Pregabalin. Therefore, a trial of Lyrica is warranted and the requested Lyrica 75 mg 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 overturnedCredentials/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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that in this clinical setting guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including Lp-PLA2, sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the advanced lipoprotein testing provided has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed at this time.  All told, Epclusa for 12 weeks 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 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 male enrollee requested authorization and coverage of Viagra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee requested authorization and coverage of breast reduction surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees pendulous breasts.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested growth hormone (GH) therapy for treatment of her idiopathic short stature (ISS).  Findings:  The physician reviewer found that in retrospect, this appears to be a young male with constitutionally delayed adolescence. Based on his height and bone age, his adult predicted height would be close to 56 according to the tables of the Greulick and Pyle Atlas. With a diagnosis of constitutional delay, the patient would be expected to attain a normal adult height without GH therapy. This prediction, though probable, is somewhat uncertain because the patient has received GH therapy for the past two years. Should his adult height prediction fall to less than 54 without GH therapy, a resumption of treatment should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee requested authorization and coverage of uterine artery embolization. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees uterine fibroids.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease.  This would apply whether or not there has been e antigen seroconversion or detectable virus, as most patients require chronic therapy given the risk of relapse when therapy is discontinued. There are no clear recommendations to stop therapy even if e antigen seroconversion is achieved. For this reason, the request for Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Two 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: All three physician 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX procedure for treatment of his medical condition.   Findings:  Three physician reviewers found that the U.S. Food and Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the literature on this device is from uncontrolled observational data.  Per the medical evidence, the superior efficacy of the LINX procedure compared to the standard reflux operation, fundoplication, has not been established.  In sum, the requested LINX procedure is not likely to be more effective than other treatment options. Final Result: Three reviewers determined that the 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 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for proton beam therapy. There is a lack of medical evidence to suggest that treatment with proton beam radiation offers a clinical benefit when compared to conventional radiation therapy techniques for breast cancer. There is scant data in the medical evidence that suggests that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. Accordingly, consensus group guidelines do not support the use of proton beam therapy in this setting (National Comprehensive Cancer Network guidelines). In the vast majority of cases, intensity modulated radiation or three dimensional conformal techniques with photons is able to achieve an acceptable cardiac and lung dose in left sided breast cancer. Also, level I evidence is lacking to support the use of proton beam therapy for the treatment of left breast cancer. 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often 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. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that 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 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 Harvoni for eight weeks for treatment of her hepatitis C virus (HCV).  Findings:  Three physician reviewers found that based on the documentation submitted for review, it is likely that this patient has advanced fibrosis. In addition, the patient is treatment naive with a low viral load and therefore eight weeks would be the appropriate duration. Final Result: Three reviewers determined that the requested medication is medically necessary for treatment.Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing.  Two 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a LINX procedure. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the U.S. Food and Drug Administration (FDA), more data is required before widespread usage can be recommended. Researchers concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, a study reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remain to be determined. Researchers found that erosion of the LINX device is an important but rare complication to recognize. Researchers noted that LINX has significant potential adverse effects and may be associated with poorer outcomes. Therefore, a LINX procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 31-year-old male enrollee has requested for emergency services for treatment of his rash. Findings:  The physician reviewer found that there is no documentation that the patient was experiencing shortness of breath, difficulty swallowing, or any airway compromise.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Afirma Gene Expression Classifier for evaluation of her medical condition. Findings: Two physician reviewers found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Given the above, the Afirma Gene Expression Classifier was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the testing 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 internal medicine with sub-specialty certification in endocrinology and metabolism 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.