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

A 51-year-old female enrollee has requested Lyrica for the treatment of her fibromyalgia. Findings:  The physician reviewer found that the medical necessity of Lyrica 75mg daily is not established based on the records provided. While it is true that Lyrica is the first drug approved by the Food and Drug Administration for treatment of fibromyalgia, the other standard drugs used for this indication  are generic, and as such, FDA approval has not been sought for these agents. The Health Plans authorization criteria for Lyrica requires that the patient try and fail a course of one other formulary alternative before receiving Lyrica. The Plans criteria are medically appropriate and consistent with the standard of care. The patient reports that she has tried other medications, but this is not confirmed in the records provided. If objective documentation is presented which confirms that the patient has failed treatment with another formulary alternative, then the patients request for Lyrica should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. Hyaluronic acid injection for osteoarthritic knee pain has become an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individual patients. With long-term use, the injections have been confirmed to be safe with no severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can all have serious systemic side effects and may not be reasonable treatment options for some patients. This patient reports consistent relief with hyaluronic acid injections. Given this support, the requested Euflexxa injections are medically necessary for treatment of this patients bilateral osteoarthritis. Final Result: The reviewer determined that the requested services 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets 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, for genotype 3 patients (regardless of cirrhosis status) who have failed Sovaldi and ribavirin, therapy is recommended with Epclusa and ribavirin for 12 weeks. This recommendation is based on clinical study data showing lack of NS5B resistance after Sovaldi use. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Upheld

The parent of a nine-month-old female enrollee, born prematurely at 33 weeks gestation, has requested authorization for two additional Synagis injections. Findings:  The physician reviewer found that according to the American Academy of Pediatrics, palivizumab prophylaxis should continue for the duration of the RSV season, with the first dose typically administered in November and the final dose administered in March to provide coverage into April. Dosing is recommended every 30 days, as the half-life of palivizumab is approximately 24 days. Although the criteria for determining the end of the RSV season is flexible, one of the more strict definitions is a positive testing rate below 10%. Some experts hold that any positive tests in a given area pose a significant risk to susceptible children. While protection through the month of April would have been medically appropriate, there is no clinical benefit in a sixth or seventh dose of palivizumab at the present time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer. Findings:  Three physician reviewers found that there is a lack of evidence in the literature to show that proton beam therapy would be superior to highly conformal photon beam treatments using intensity modulated radiation therapy (IMRT).  There is no randomized trial directly comparing the efficacy of protons and photons in treatment of clinically localized prostate cancer.  The study by Tromifov and colleagues performed a dosimetric comparison of 10 patients whose treatments was planned with protons and photon IMRT to a dose of 79.2 Gy. This study found that IMRT actually yielded better dose conformity. The study by Hall and colleagues showed that the treatment with proton may result in an increase in total body dose to the patient from neutron scatter beyond the acceptable limits and actually lead to a higher risk of second malignancies than treatment with IMRT.
Appeal type: Urgent Care
Decision: Upheld

A 20-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patient had a one day history of mild bilateral ear pain.  Due to the fact that she was not in severe pain and that her life and well-being were not in jeopardy, the Prudent Layperson Standard is not met.  Her complaints were not of sufficient severity that would lead a patient to make a reasoned decision to seek immediate care in an emergency department.  It was not likely that any delay would result in serious jeopardy to her health or function.  Her condition was urgent and not emergent.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested occupational therapy for treatment of his autism.  Findings:  The physician reviewer found that the prevalence of impairments in fine and gross motor skills appears to be relatively high, based on the few studies that have included such information in autism or pervasive developmental delay. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. They help set specific goals for the person with autism. These goals often involve social interaction, behavior, and classroom performance. Occupational therapists can help in two main ways: with evaluation and therapy. To support the need for occupational therapy, studies have shown that occupational therapy prevents a deterioration or reversal of function and results in significant improvement in activities of daily living. In 2008, Case-Smith and Arbesman evaluated six categories for the need of occupational therapy and showed that in all six areas occupational therapy significantly helped the patient. Additionally, this patient carries a diagnosis of Fragile X syndrome. In an article describing children with Fragile X syndrome, with and without autism, the authors were able to demonstrate that the relationship between lower IQ or even lower fine motor skills in those with Fragile X syndrome and ASD compared to Fragile X syndrome alone might be explained by additional genetic or medical insults to the brain. These insults would introduce barriers to the motor or cognitive or social development of these children in addition to the Fragile X syndrome diagnosis. (Zingerevich, C., et al.) Occupational therapy usually addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development in children with Fragile X syndrome. In addition, a therapeutic regimen that includes occupational therapy can help focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development.This patient has documented sensory deficits, as well as delays in his self-help skills, which need to be addressed as stated in the guidelines from the American Academy of Neurology (AAN). Therefore, it is recommended that the requested occupational therapy be provided with reassessment every six months to determine if ongoing occupational therapy is needed.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that although this patient could benefit from bariatric surgery, because she continues to smoke, the requested surgery should not be authorized. If and when the patient is able to establish that she has ceased smoking, the requested surgery should be considered by the Health Plan. However, at this time the surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  The current medical evidence supports the requested medication in this clinical setting.  The requested treatment regimen is expected to potentially prevent further damage of the liver and disease progression.  It is advantageous to initiate treatment for patients with early stage disease.  All told, the requested Harvoni for eight weeks is medically indicated for the treatment of this patient.  Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for treatment of morbid obesity.  Findings:  The physician reviewer found that the patient meets nationally recognized criteria for authorization of bariatric surgery. The Medicare Coverage Database states gastric bypass, duodenal switch and Lap Band are covered in patients with a BMI greater than 35 and at least one obesity-related co-morbidity. Current literature indicates the Lap Band produces substantial weight loss with low morbidity. The weight-loss curve very closely approximates that of gastric bypass at five years and patients who undergo the Lap Band procedure are less likely to have potentially life threatening adverse events.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees risk for breast cancer. Findings:  Two 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 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 performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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

The parents of an eight-month-old male enrollee requested authorization and coverage of the medication Synagis. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested a breast MRI for an evaluation of her breast lump. Findings:  Three physician reviewers found that the current standard of care and burden of evidence as reflected in the American Cancer Society guidelines for breast cancer screening supports limiting MRI use to women with high risk of breast cancer. These guidelines provide that women who meet the following criteria are considered high risk: documented BRCA mutation, a first degree relative with documented BRCA mutation, a history of radiation to the chest between ages 10 and 30 or two first degree relatives with breast cancer. Review of the clinical evidence provided does not demonstrate that the patient meets any of these criteria. The use of MRI in women who are not high risk for breast cancer is not supported by peer-reviewed scientific literature. In fact, women at lower risk are advised against it, given the risk of falsely positive findings.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested colonoscopy is not medically necessary for evaluation of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested colonoscopy is 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 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 (Helvie). In this particular patient, the presence of breast implants is not, in itself, an indication for tomosynthesis but the dense nature of her breast tissues warranted the use of 3D tomosynthesis.  It is specifically those 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. Therefore,  tomosynthesis was likely to be more efficacious than any available standard screening tool for evaluation of the patients medical condition.  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

The parent of a five-year-old female enrollee has requested for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that speech therapy initiated at a young age can result in marked improvement in children with major speech problems and impairments similar to those of this patient. Intensive therapy is necessary to allow the patient to acquire normal social interaction and communication skills. Individual therapy at an early age is medically appropriate and indicated based on the severity of this patients deficits. Speech therapy once a week for 10 weeks should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

A 43-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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 23-month-old male enrollee has requested speech therapy for treatment of the enrollees language delay.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested speech therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are optimal.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  The current medical evidence supports the requested therapy in this clinical setting.  Broomfield and Dodd noted the benefit of speech and language treatment compared to no treatment in children with primary speech and language impairment.  In this patients case, he demonstrates expressive language delays that are negatively impacting his ability to communicate and interact successfully with his environment. The literature supports the use of speech and language therapy to address expressive deficits and facilitate development of age-appropriate communication skills.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Afirma gene test for evaluation of her medical condition.  Findings: Three physician reviewers found that the patients biopsy showed a follicular thyroid lesion of undetermined significance. The requested Afirma gene test in similar clinical situations is an accepted standard for further evaluation. Moreover, the Afirma test is consistent with the recommendations from the National Comprehensive Cancer Network (NCCN) to help determine the malignant potential. For these reasons, the requested Afirma gene test is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested testing is 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 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: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of gastric reduction with duodenal switch for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a gastric reduction with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.