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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza, Sovaldi, and weight-based ribavirin for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) for patients with HCV genotype 3 infections with cirrhosis, in whom prior treatment with sofosbuvir and ribavirin has failed the recommended regimens include two treatment options. Daily daclatasvir (Daklinza) and sofosbuvir (Sovaldi) for 24 with weight-based ribavirin for interferon ineligible patients and daily sofosbuvir (Sovaldi) and weight-based ribavirin plus weekly peginterferon for 12 weeks for interferon ineligible patients. In the ALLY-3 study, seven patients previously treated with sofosbuvir-containing regimens were retreated with daclatasvir and sofosbuvir for 12 weeks. Of these patients, 5 (71%) achieved a sustained virologic response (SVR) at 12 weeks. Based on these limited data, 12 weeks of daclatasvir and sofosbuvir is likely to be insufficient, and extending the duration to 24 weeks of therapy and adding weight-based ribavirin is recommended. HCV treatment is medically necessary in this clinical setting. Although the patients records do not support interferon-ineligibility, the two AASLD/IDSA guidelines are equally rated. Moreover, the Daklinza-containing regimen is likely to be better tolerated and as such, the requested medications are medically necessary.  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-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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of his renal cell carcinoma. Findings:  Two physician reviewers found that in this patients case, the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is lack of support for the services at issue.  Genomic assays may find multiple genetic alterations.  There is little data available to suggest that targeted genetic therapy affects outcomes.  There is a lack of evidence indicating that the gene testing performed was likely to have been more beneficial than available standard therapy.  All told, the gene testing at issue was not likely to have been of greater benefit than other modalities.  Final Result: Two 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 48-year-old female with degenerative disc disease and myofascial neck pain. She has been receiving physical therapy (PT) and it has apparently been helpful.  The patients provider prescribed continued physical therapy and aquatic evaluation and therapy.  The patients request for authorization of continued physical therapy and aquatic evaluation and therapy was denied by the Health Plan based on a determination that the therapies are not medically necessary.A review of the record shows that the patient was receiving physical therapy and that it was beneficial.  Some instruction in a home exercise program was provided, but the PT progress notes indicate the patient had not been fully instructed. Since land-based physical therapy was helpful to the patient, aquatic therapy would not be medically necessary at this time.  The patient should continue with the land-based physical therapy in order to complete all of the instruction necessary for a home-based exercise program. Three times per week for three weeks would be a reasonable time frame.  Based upon the information set forth above, I have determined one of the requested therapies is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested a genioplasty procedure for the treatment of his Class II malocclusion with an anterior open bite. Findings:  The physician reviewer found that the patient has a maxillofacial skeletal deformity, specifically mandibular hypoplasia. These types of deformities may be apparent at birth or may manifest during subsequent growth and development creating functional, degenerative, cosmetic and/or psychological problems. Given the degree of this patients deformity, his mandibular hypoplasia/microgenia did constitute an abnormal body structure which was caused by a congenital and/or developmental abnormality. The advancement genioplasty was performed to create a normal appearance to the extent possible and improved the function of the mentalis muscle and lower lip. It did offer more than a minimal improvement in the patients appearance. The surgery was medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left heart cardiac catheterization and coronary angiography. Coronary microvascular dysfunction (CMD) is a broad term that, in the absence of obstructive coronary disease, includes any pathology that may disrupt the microvasculature, including endothelial dysfunction, coronary spasm, inflammation, and atherosclerosis. There are a number of imaging methods available to measure myocardial blood flow in the setting of microvascular dysfunction. The American College of Cardiology (ACC) and American Heart Association (AHA) guideline for the evaluation and diagnosis of chest pain note that the use of invasive coronary function testing is reasonable in patients with suspected ischemia with non-obstructive coronary disease (INOCA) to improve the diagnosis of CMD and to enhance risk stratification when there is evidence of persistent chest pain, nonobstructive coronary artery disease, and myocardial ischemia. These components did appear to be present in this patient. In this clinical setting, cardiac catheterization with coronary function testing for evaluation of suspected CMD or INOCA is medically indicated. Therefore, left heart cardiac catheterization and coronary angiography are medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested authorization and coverage of the medication Remicade. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees ulcerative colitis.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested therapy is more beneficial than any available standard therapy. Because two of three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) for treatment of the enrollee who has been diagnosed with cutaneous basal cell carcinoma.  Findings:  Two physician reviewers found that there is a growing body of literature supporting the use of IMRT for extremity sarcoma.  The use of radiation treatment for resected, node positive skin cancer is a standard treatment. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. For extremity soft tissue sarcomas, IMRT is used to spare bones, joints, lymphatic channels, nerves and critical organs.  IMRT is often better suited for extremity sarcomas than conventional radiation, because of the concave dose distribution, which is difficult to achieve with conventional radiation. IMRT is another effective means to deliver radiation.  In general, IMRT can be clinically meaningful in the reduction of normal tissue exposure and/or target coverage. From the provided records, and the description of where the target is located, IMRT is a more effective manner to treat the target and to spare the surrounding normal tissues than 3-dimensional (3D) conformal radiation. The use of IMRT is adequately justified in this case. With regards to IGRT, this procedure is generally done in conjunction with IMRT. Because IMRT is a conformal way to deliver radiation, IGRT is needed to verify set up on a daily basis. Therefore, IMRT and IGRT are likely be more beneficial for treatment of this patient than the standard 3D conformal radiation. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in radiation 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Botox injections treatment of the enrollees medical condition. Findings:  The physician reviewers found that while the documentation regarding the patients history of migraines is limited, the records support the diagnosis of hemifacial spasms. This patients record indicates that following Bells palsy, the patient experienced hemifacial spasm and synkinesis. Bells palsy may be caused by a viral infection of the facial nerve. Upon healing, some patients develop synkinesis or facial spasm. The medical literature indicates that hemifacial spasm is usually due to compression of the seventh cranial nerve at its exit from the brain stem. The submitted records indicate that the Botox therapy administered was for the treatment of this patients hemifacial spasms and pain. The medical literature supports Botox therapy for treatment of this patients hemifacial spasms and pain. Moreover, as Botox therapy usually lasts for about three months, ongoing treatment is appropriate.  Therefore, the services at issue were and are more likely to be superior to other therapies for the treatment of this patient. Final Result: Two of three  reviewers determined that the services at issue were and 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: Physician reviewers number one, two, and three are board certified in neurology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the proton beam radiation therapy provided Findings:  The physician reviewer found that there is currently a lack of medical literature to support treatment with proton beam radiation as compared to conventional radiation therapy for patients with metastatic renal cell cancer to the lung. Standard treatment with photon radiation is associated with a very low risk of toxicity. In addition, there is a paucity of data demonstrating that treatment with proton techniques improves sparing of the surrounding normal structures compared to standard photon techniques using intensity modulated radiation therapy (IMRT) or stereotactic body radiotherapy (SBRT). Further, consensus group guidelines do not support the use of proton therapy in this setting. Based on these reasons, the proton beam radiation therapy provided was not likely to be more beneficial than standard therapy.Final Result: All three of the reviewers determined that the services at issue were 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 & 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment for treatment of the enrollees bipolar disorder. Findings: The physician reviewer found that this patients records do not support the medical necessity of residential treatment center (RTC) level of care services. The patient denied suicidal and homicidal ideation. She demonstrated no self-harm behaviors and she has not been aggressive or threatening towards others. She has been independent in self-care and cognitively intact. Overall, there is a lack of evidence that the patient required the intensity and supervision provided at the RTC level of care. Given these findings, the RTC services were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in child and adolescent 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air and ground ambulance transportation services for treatment of the enrollees traumatic brain jury. Findings:  The physician reviewer found that the air ambulance and ground ambulance transportation services were medically necessary for treatment of the patients medical condition. In this case, the patient sustained a brain injury and hip fracture over one thousand miles from home. The patient was recommended for inpatient rehabilitation at RIC for treatment of functional deficits related to hip fracture surgery and a brain injury. Due to his weight bearing restrictions and confusion, medical monitoring during air travel was medically necessary. To receive early specialized rehabilitation with his support network, the patient required transport home by air ambulance. As such, transport home by air and ground ambulance was medically necessary for the patient to receive early specialized rehabilitation in close proximity to his support network. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested an oxygen concentrator for treatment of his heart condition.   Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The patients oxygen saturation on room air was normal. The lung volumes, flow rates and diffusion capacity were normal.  There is no documentation of hypoxia. Assuming significant heart disease, there is no documentation of oxygen saturation on room air of 89% or lower. Dyspnea on exertion is not an indication for oxygen therapy.  All told, the requested oxygen concentrator is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 internal medicine with sub-specialty certification in pulmonary 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 authorization and coverage for Supartz injection series in the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed conservative treatments. The alternative is a total knee arthroplasty, which the patient does not want because of her experience with the right knee. Therefore, the requested Supartz injection series for the left knee is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cardiac rehabilitation for treatment of her medical condition.  Findings:  The physician reviewer found that in this patients case, the submitted medical records do not demonstrate she presents with a condition that is likely to benefit from cardiac rehabilitation services. The effectiveness of post-operative cardiac rehabilitation services for patients who have undergone heart tumor resection has not been established. For these reasons, the requested cardiac rehabilitation services are not medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old male enrollee has requested occupational therapy (OT) for treatment of his nonverbal learning disorder.  Findings:  The physician reviewer found that the goal of a medically necessary rehabilitation treatment modality, such as occupational therapy, is to restore an individual's ability to function as normally as possible after a disabling illness or injury. According to the documentation provided, the patients cognitive issues are mild and he is not disabled by them nor is he recovering from an illness or injury that resulted in a loss of function.