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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, this patient meets the criteria for RTC services. This gives the patient a composite score which is consistent with medically monitored non-residential services. This level of care provides supervision of activities of daily living, which is a requirement for this patient given his decompensation and failure of higher levels of care. All told, the RTC services provided were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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

A 44-year-old female enrollee has requested for Botox injectionsfor treatment of her piriformis syndrome. Findings:  Three physician reviewers found that a review of the medical literature and the materials provided does not confirm the efficacy of Botox for the treatment of piriformis syndrome. Overall, scientific studies fail to document the efficacy of Botox in musculoskeletal chronic pain disorders. Thus, Botox remains an unproven therapy for the purpose of treating buttock pain in the setting of piriformis syndrome.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 24 weeks for treatment of the enrollees hepatitis C virus. 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), no data are available for retreatment of Sovaldi and Daklinza failures in genotype 3 patients; Epclusa and ribavirin for 24 weeks may be considered for those who require immediate re-treatment, such as patients with cirrhosis, as in this case. Per the guidelines, patients with diabetes mellitus are at risk for faster disease progression. The guidelines state that available data comes from patients who have failed Epclusa. 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: Medical Necessity
Decision: Overturned

A 50-year-old male 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 super 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The American Association for the Study of Liver Diseases and Infectious Diseases Society of America note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The medical literature supports the requested medication for the treatment of this patient.  All told, Harvoni for 12 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor.  Based on the documentation submitted for review and peer reviewed literature, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewer 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: The reviewer is board certified in diagnostic radiology 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 35-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, 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 (Skaane, et al). Given the support above, breast tomosynthesis 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 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 Sovaldi for treatment of his medical condition.  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), 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. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, treatment with Sovaldi is 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C. 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, and advanced fibrosis is not required for treatment.  Per guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni.  Non-cirrhotic patients with a viral load of less than 6,000,000 IU/mL, such as this patient, can be treated for eight weeks.  The guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Harvoni for eight weeks is 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 physician 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C virus (HCV).   Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) guidelines, relative to this patients case, state: `Daily daclatasvir (60 mg*) plus sofosbuvir (400 mg) for 12 weeks is a recommended regimen for treatment-naive patients with HCV genotype 3 infection who do not have cirrhosis. Rating: Class I, Level A`.  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. However, the submitted records reflect illicit drug use. In the context of achieving the medically necessary goal of hepatitis C virus eradication, active recreational use of illicit substances raises concern for non-optimal adherence to hepatitis C treatment. The literature supports that frequent drug use during treatment was associated with lower sustained virologic response rates than drug abstinence. In the context of achieving the medically necessary goal of HCV eradication, the patients positive drug screen raises concern for non-optimal adherence to HCV treatment, when provided. As such, the requested medications are not medically necessary for treatment of the patients medical condition at this time. Final Result: The reviewer determined that the requested medications 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 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

A 44-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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 procedure is not medically necessary for treatment of the patients 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 as a problem solving adjunct to routine mammography. Specifically, those patients who have dense breasts can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given this support, 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 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 parents of a three-year-old male enrollee have requested for speech therapy for treatment of the enrollees speech delay.    Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability, and is related to school success. 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 best. Untreated speech and language delay in preschool children has shown variable persistence rates (from 0% to 100%), with most studies reporting 40% to 60%.  Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. They may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. This may lead to overall academic underachievement and, in some cases, lower IQ scores that may persist into young adulthood. In addition to persistent speech and language-related underachievement (verbal, reading, spelling), language-delayed children have also been shown to have more behavior problems and impaired psychosocial adjustment. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. Overall, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for orthodontic dental treatment. In this clinical setting, while the records note that the patient has an overbite, the presence of an overbite in and of itself is not an indication for orthodontic therapy. Given the handicapping labio-lingual deviation (HLD) score of 21, there is a lack of support for the requested orthodontic dental treatment. Orthodontic treatment is also not the appropriate treatment modality for pain from a third molar impaction. Therefore, orthodontic dental treatment is not necessary to prevent disease and promote oral health or restore oral structures to health and function in this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed D.D.S., board certified in dentistry 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 reimbursement for occipital nerve block injections for treatment of the enrollees occipital neuralgia. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This patients pain complaints are corroborated by physical examination and medical history. In particular, there is objective documentation of occipital neuralgia to substantiate the need for occipital nerve blocks. In addition, the patients occipital neuralgia has been unresponsive to conservative measures, including neuropathic pain medications and muscle relaxants. The medical evidence supports occipital nerve block injections in this case. Therefore, occipital nerve block injections were likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were 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 anesthesiology with sub-specialty certification in pain medicine 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 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 the treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that the American College of Radiology (ACR) has urged tomosynthesis to be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging. Thus, the addition of tomosynthesis 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 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: The reviewers are board certified in diagnostic radiology and is actively practicing. The reviewers are 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.