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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries. The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary gender affirming surgery. Specifically, the WPATH states that, non-genital surgical procedures...notably facial feminization surgery...are often of greater practical significance in the patients daily life than reconstruction of the genitals. Further, the WPATH asserts that these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. A study reported that facial feminization, like genital surgery, improved mental health quality of life. The records provided for review document clinically significant symptoms due to gender dysphoria related to masculine features of her face. The patient meets the WPATH criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features. Therefore, the requested facial feminization surgeries are supported as medically necessary for treatment of this patients distress related to gender dysphoria. Final Result: The reviewer determined that the requested surgeries 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 psychiatry 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 DecisionDx-Melanoma Assay. Findings:  Three physician reviewers found there is a lack of support for the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Therefore, DecisionDx-Melanoma Assay was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with 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: Overturned

A 35-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested therapy. The peer-reviewed literature demonstrates positivism for TMS while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama et al). Further, TMS has been cleared by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. Based on the medical records provided, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate treatment and consistent with good medical practice. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness and therefore, medically necessary.
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 the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis allows radiologists to separate glandular elements from architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For this reason, the addition of breast tomosynthesis to two-dimensional imaging was likely of more benefit to the patient than had the examination been done with two-dimensional imaging alone.  Therefore, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. 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 regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Additionally, the guidelines recommend that patients with certain extrahepatic manifestations such as cryoglobulinemia be treated. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: 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 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, by separating the various layers of breast tissue, one can better detect abnormalities. Specifically, 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. All told, in this clinical setting, the use of the digital 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 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: Medical Necessity
Decision: Overturned

The patient is a 13-year-old female who has been diagnosed with obsessive-compulsive disorder with delusions and attention-deficit hyperactivity disorder. The patients medication regimen includes prescribed Lexapro and Focalin. The Plan has denied coverage for Lexapro on the basis it is a non-formulary medication and is not medically necessary.Since the patient is stable it would be inappropriate to stop her current medication regimen in order to give a trial of formulary medications, which may or may not be effective. Furthermore, Lexapro has a unique mechanism of action (receptor binding affinities, etc.) and generic equivalents do not exist. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
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 the American College of Radiology (ACR) has recommended tomosynthesis be removed from the investigational category due to the advantages it provides radiologists in interpreting mammograms. This tomographic method allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) imaging protocol was likely of greater benefit to the patient than 2D imaging alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). SBRT, delivering high fractional doses in four to five fractions is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is appropriate when the patients performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks. Thus while this patient does not have oligometastatic disease, the need for SBRT has been established based on prior radiation and histology of the metastasis. Thus, the requested SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology 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 Afirma gene expression classifier testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that while a fine needle aspiration (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 (Alexander et al). 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 (Miller et al).  A relatively new test, the Afirma Thyroid FNA Analysis, 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 (Duick et al). Therefore, the diagnostic test at issue was likely to be more beneficial for the evaluation of this patients medical condition than any available standard therapy. Final Result: Three 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.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 41-year-old male enrollee has requested temporomandibular joint (TMJ) dysfunction treatment (CPT code 99354, prolonged physician services) for treatment of his TMJ dysfunction. Findings:  The physician reviewer found that the evaluation of patients with orofacial pain is generally more involved than a routine dental patient. The exam consists of a detailed history and a thorough physical exam of the head and neck. In this patients case, an extended new patient exam was coded for and appropriate for the work-up of the patient. However, given this, it is unclear for what additional purpose a prolonged physician service was also coded for in that there was no documentation submitted to support this additional billed code.
Appeal type: Experimental/Investigational
Decision: Overturned

A 36-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that Botox is an accepted treatment for various types of headaches for patients who have failed standard therapies. A trial of Botox is usually appropriate after having tried and failed three to four prophylactic agents and various abortive medications. The evidence in this case indicates the patient failed to respond to trials of several abortive and prophylactic medications. As such, Botox therapy was medically indicated and has been shown to be effective for the patient.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested a bilateral reduction mammoplasty for the treatment of her macromastia. Findings:  The physician reviewer found that the submitted clinical notes do not contain findings of intertrigo. While the patients primary care physician makes reference to chronic shoulder, back and neck pain, treatment notes documenting the chronicity of these complaints have not been provided. The low back complaints are not attributable to breast hypertrophy, though the upper back pain can be causally related to large breasts or other intrinsic cervical or thoracic etiology, the source of which has not been adequately documented in the supplied records. All told, there is inadequate evidence that the proposed mammoplasty is clinically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 13-year-old male enrollee has requested for human growth hormone (GH) therapy for treatment of the enrollees short stature.  Findings:  Two physician reviewers found that the FDA approval of GH therapy for children with idiopathic short stature indicates GH is appropriate for patients who are below the -2.25 standard deviation in predicted height. This patient does not meet this requirement as his predicted adult height exceeds the FDA cut-off. The use of Letrozole may promote some improvement in the prediction.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks.Epclusa 400-100 mg tablets for 12 weeks is one of two recommended therapies for hepatitis C, genotype 2 without associated cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommend treatment of all patients with documented hepatitis C without regard to their level of fibrosis. The AASLD/IDSA guidelines note, Therefore, the panel continues to recommend treatment for all patients with chronic hepatitis C infection, except those with a short life expectancy that cannot be remediated by hepatitis C treatment, liver transplantation, or another directed therapy. The current medical evidence supports the requested medication regimen in this clinical setting. Therefore, Epclusa 400-100 mg tablets for 12 weeks are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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 infectious 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:   An enrollee has requested Viekira Pak for treatment of her hepatitis C.  Two physician reviewers found that according to the 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, regardless of fibrosis, should be treated except patients with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The current medical evidence supports Viekira Pak for treatment-naive patients.  Based on evidence of safety and efficacy in the published literature, the requested Viekira Pak 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: 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee is requesting Harvoni for the treatment of her hepatitis C infection. 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 4 patients should be treated with Harvoni for 12 weeks. The guidelines also recommend Technivie/ribavirin for 12 weeks. However, the guidelines specifically recommend against the use of Technivie (or Viekira Pak) with a medication this patient takes.  For these reasons, Harvoni is medically indicated 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 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.