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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested rituximab for treatment of her medical condition.  Findings:  Two physician reviewers found that the medical records indicate a condition of primary progressive MS for which the current peer-reviewed literature does not support rituximab as a proven therapy. Studies have not demonstrated significant improvement with this therapy for primary progressive MS. He and colleagues noted there is insufficient evidence to support the use of rituximab as a disease-modifying therapy for MS because only one randomized controlled trial is available for review. Hawker and colleagues findings did not reach significance. All told, there is a lack of scientific data demonstrating that the requested rituximab is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested medication 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:  All three reviewers are board certified in internal medicine and neurology 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 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. 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 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 protocols was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis performed 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: Upheld

A 56-year-old male enrollee requested authorization and coverage of a colonoscopy as a screen for cancer.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested magnetic resonance imaging (MRI) of the breasts for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that the published medical literature indicates that MRI may be used as a problem solving tool when imaging or clinical findings are equivocal, but still concerning. In this case, the breast parenchyma is mammographically very dense, limiting the utility of this technique for this patient. Coupled with the strong family history and vague area of fullness on physical examination, despite a negative ultrasound, MRI would be of benefit in evaluating her condition due to the high sensitivity of the technique. For these reasons, the requested diagnostic procedure should be approved as it is likely to provide useful data in the evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested chiropractic care for treatment of her pain. Findings:  The physician reviewer found that clinical guidelines vary regarding the benefits of manipulation for the management of low back pain. Patients may achieve similar outcomes from chiropractic care and standard physical therapy. Other interventions, such as patient education, increased physical activity, and home exercise programs, may play an equally important role in the overall management of low back pain. In this case, the documentation does not support the medical necessity of subsequent and ongoing chiropractic manipulation. All told, chiropractic care was not and is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Therefore, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.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. 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 60-year-old female enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch (DS) for treatment of her morbid obesity.   Findings:  The physician reviewer found that with a BMI of 43.2 and multiple comorbid conditions, the patient met nationally accepted medical necessity criteria for consideration of weight loss surgery. Peer reviewed  articles clearly demonstrate superior weight loss and maintenance of weight loss over the long term with the DS as compared to other surgical procedures. Published data also demonstrates that the Roux-en-Y procedure results in as much, if not more, protein calorie malnutrition as the DS. The patients assertion that the DS is the most effective surgical weight loss alternative is well supported in the literature and this option was a medically reasonable approach to surgical weight loss. Psychological, nutritional and cardiology evaluations indicated the patient was an appropriate candidate for the surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees migraine/headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. All 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. Because all 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

A 39-year-old female enrollee has requested for Botox injections for treatment of her migraine.   Findings:  Two physician reviewers found that the literature shows that Botox can be beneficial for individuals with chronic headache, including those with medication overuse.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks. Findings:  The physician reviewer found that according to the 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A (NS5A) resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infectionFinal 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 digital breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that breast 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast was likely to have been more efficacious than 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that based on the guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), treatment with direct acting antiviral drugs should be prioritized for patients with the greatest likelihood of achieving benefit with viral eradication. The guidelines note that the highest priority patients include those who are at highest risk of substantial morbidity from untreated hepatitis C virus infection, such as those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of hepatitis C. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis as demonstrated by Metavir stage F2, human immunodeficiency virus (HIV) coinfection, coexisting liver disease, or diabetes mellitus. This patient has not demonstrated that he should be categorized as a high priority patient. Accordingly, the requested 12 week course of Harvoni is not supported as medically necessary for treatment of the patients medical condition. Final Result: Three reviewers 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is support in the medical literature showing that the addition of digital breast tomosynthesis to two-dimensional mammography reduces false positives and increases cancer detection when compared to mammography alone (Ciatto, et al). According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the support in the peer-reviewed literature, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone . Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis . Given the support above, the digital breast tomosynthesis performed on the date of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that 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: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all 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 Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that the medical necessity of HCV eradication as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations exists irrespective 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). The records provided demonstrate that this patients life expectancy exceeds this limit. However, in this case, the provider requested a 12 week course of Harvoni.  In patients with viral loads less than 6 million IU/mL, an 8 week course of Harvoni is considered medically appropriate. Kowdley and colleagues state, `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` This patient is treatment-naive without cirrhosis and according to the study performed by Kowdley and colleagues there is no additional benefit to an extended 12 week course of Harvoni in this clinical setting. Therefore, Harvoni for 12 weeks is not medically necessary for treatment of this patients HCV.  Final Result: The reviewer determined that the requested medication regimen 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 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 46-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male enrollee has requested vision therapy for the treatment of the enrollees strabismus. Findings:  The physician reviewer found that strabismic patients exhibiting esotropia with many associated conditions (likely anomalous correspondence, no fusion  similar to this patient) tend to be the most difficult to successfully treat with vision therapy. These patients require extremely aggressive programs of vision therapy, none of which can be administered to a two-year-old toddler. In general, the treatment period tends to be lengthier for long-standing, infantile esotropia than other types of strabismus.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. In this case, the patients mental health professionals noted that it is not in the patients best interest at this time to be treated with opioids. In addition, the medical literature supports the use of alternatives to opioids for the treatment of this patient. In this patients case, there was no objective functional loss reported in the documentation when the patient was weaned off the opioids. Instead, there is documentation of being a danger to himself while on opioids. Furthermore, there is no objective treatment goals for pain and function noted for the requested medication. Also, in this case, not all non-opioid treatment options have been utilized. The records do not document that different types of behavior therapy have been exhausted despite significant research to support its use. Finally, not all non-opioid medications classes have been optimized or tried. For these reasons, Norco is not medically necessary for the treatment of the patients medical condition.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.