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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Guardant360 test for evaluation of the enrollees lung adenocarcinoma. Findings:  The physician reviewer found that In the peer-reviewed medical literature, Guardant360 testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Guardant360 test, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of Guardant360 test in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Guardant360 test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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 patient is a 52-year-old woman with recurrent/refractory ovarian cancer. She was originally treated in November 2002 for Stage III disease with a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and partial colectomy with primary re-anastomosis. She received adjuvant chemotherapy of alternative regimens of gemcitabine/carboplatin and carboplatin/paclitaxel as part of her enrollment in GOG 182. She developed recurrent disease in March 2004 manifested by a rising CA125 and has undergone additional chemotherapy consisting of gemcitabine/cisplatin, followed by Doxil, then Xeloda, then Hexalen, and finally topetecan, with no further therapy since April 2005. Her most recent CT scan of 5/5/05 demonstrated likely recurrence along the greater curve of the stomach, jejunum, and in the pelvis adjacent to the rectum. In addition, a very low-grade localized partial bowel obstruction due to the jejunal recurrence is noted. The patient consulted an out-of-network provider who recommended debulking surgery with retrieval of tumor for chemosensitivity assay and subsequent chemotherapy based on the results of this assay. The Health Plan indicates the proposed surgery can be performed by an in-network provider.The patient wishes to have tumor debulking surgery performed by an out-of-network provider. The Health Plan indicates the proposed surgery can be performed by an in-network provider. There is no evidence that medically appropriate surgical care is not available in-network. Furthermore, there is no evidence the outcome of surgical services performed by the out-of-network provider will be superior to the results obtained by the in-network provider. Since appropriate care is available in-network, it is not medically necessary that the patient obtain surgical services from an out-of-network provider. As such, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested sacroiliac joint fusion for treatment of the his sacroiliac pain.  Findings:  Three physician reviewers found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS) well selected patient can benefit from sacroiliac joint fusion. According to the ISASS guidelines, patients who have significant sacroiliac joint pain confirmed with at least three physical examination maneuvers that stress the sacroiliac joint, have confirmation that the sacroiliac joint is the pain generator with 75% or greater relief with fluoroscopically guided diagnostic intra-articular sacroiliac joint block using local anesthetic, and have failed to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest; physical therapy; and sacroiliac joint steroid injection, may be a good candidate for sacroiliac joint fusion. This patient has pain rated 8/10, confirmed by three physical examination maneuvers that stress the sacroiliac joint, and his pain interferes with his ability to perform activities of daily living. In addition, the patient had three diagnostic sacroiliac joint injections which gave him greater than 75% relief and has failed to respond to more than six months of conservative therapy. Moreover, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Final Result: The reviewers determined that the requested surgery is 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 orthopedic surgery and is 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services, such as RTC level of care. For dimension 1, intoxication and withdrawal potential, the patient was noted to be withdrawing from multiple substances on admission. For dimension 2, biomedical issues, the patient needs to achieve and maintain sobriety in order to complete her hepatitis C treatment. Dimension 3 evaluates a patients emotional, behavioral, and cognitive issues. The records document comorbid PTSD and major depressive disorder requiring treatment. Dimension 4 addresses a patients readiness to change. This patient still requires redirection to address her behaviors that lead to isolation which results in substance use. For dimension 5, relapse and continued use problem potential, the patient has a history of multiple relapse and readmissions in large part due to her self-medicating her stress. She has been assessed to be in imminent danger to herself and relapse if discharged from the structure of the RTC. Dimension 6 focuses on a patients recovery environment. This patients records report that she has no support other than her mother and spouse. Based on these findings, the patient requires safe and stable living environment in order to develop her recovery skills. Given the severity of the patients illness, RTC services 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 with expertise in addiction 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for high frequency chest wall oscillation (HFCWO). Tracheomalacia is an anomaly of the upper respiratory tract characterized by dynamic collapse of the trachea during expiration, resulting in airway obstruction and poor mucous clearance. Left untreated, tracheomalacia leads to mucous impaction, recurrent pulmonary infections, and irreversible airway damage called bronchiectasis. In patients with bronchiectasis, HFCWO devices have been demonstrated to improve mucous clearance, thereby optimizing pulmonary hygiene to avoid irreversible airway damage from bronchiectasis. This patient required an aggressive mucous clearance program to forestall irreversible airway damage and avoid hospitalizations from recurrent pulmonary infections. Initiating therapy with a HFCWO device in this patient is within standard practice. Given these findings, the HFCWO device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the HFCWO device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was 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 reviewer 1 is board certified in pediatrics with subspecialty certification in pediatric pulmonology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease and is 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: An enrollee has requested reimbursement for skilled nursing facility including therapy services and has requested the resumption of skilled nursing facility including therapy services. Findings:  The physician reviewer found that the documentation provided do not support the medical necessity of the services at issue in this clinical setting. Stroke is a leading cause for severe disability in the community, resulting in multiple deficits including community mobility deficits. It is also among a variety of conditions that increase risk of influenza complications. In this case, the patient has chronic mobility deficits, and requires use of mobility aides. The records noted that his baseline is the use of a cane, wheelchair or motorized scooter. Due to the patients baseline condition, his recovery has been protracted. He also became deconditioned due to influenza.  The patient had made modest progress but he continued to require significant assistance for his basic self-care and mobility, including transfers.  As such, the documentation provided support continued care but in a less intensive setting. Therefore, the skilled nursing facility including therapy services provided and the resumption of skilled nursing facility including therapy 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 physical medicine and rehabilitation 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:  The enrollee is requesting authorization and coverage for a power wheelchair (Group 3). The enrollee has spinal paralysis, chronic pain, neuropathy, hypertension, uncontrolled type-2 diabetes, and hyperlipidemia. At an office visit, the enrollee requested an electronic wheelchair for increased mobility. He had right shoulder pain for many months. His provider prescribed an x-ray and a referral to durable medical equipment for the power wheelchair.  The enrollee indicates his ability to use a regular wheelchair is limited. He reports limitations of strength, endurance, range of motion, and coordination. He has pain and muscle spasms in his lower back impair his ability to push himself. This enrollee lives at home with his family, in a wheelchair-accessible home.  He has 24-hour formal and informal care for his needs.  He can independently propel his standard manual wheelchair; however, community access is limited.  A durable medical equipment evaluation noted the enrollee is able to self-propel a manual wheelchair. His upper extremity strength was noted to be 4/5. The records do not support that this enrollee's condition could not be managed with a lesser device, such as a group one power-mobility device or lightweight manual wheelchair.  The necessity for a group three device is not established. Literature indicates individually configured manual wheelchairs improve the ability to self-propel, prolonging mobility and endurance and preventing the development of secondary problems. Literature indicates bimanual, lever-driven propulsion has the potential to exercise healthy movement synergies, which may in turn help drive use-dependent motor recovery. Studies show motorized wheelchairs can have detrimental long-term effects by increasing cardiovascular risk and insulin resistance.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested microvascular lymphatic reconstruction surgery for the treatment of her lymphedema. Findings:  The physician reviewer found that this patient does not have many options. The conservative measures she has tried have not worked. There is literature to support this procedure. Because there are very few experts dealing with this problem, considerable weight should be given to the physicians willing and able to deal with this complicated process of post-mastectomy/radiation lymphedema. There are no adequate alternatives for this patient, and the requested procedure is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the deep vein thrombosis (DVT) prevention system (E0673  segmental gradient pressure pneumatic appliance, half leg). Findings:  Two physician reviewers found that minor injuries in the leg are associated with greater risk of venous thrombosis. A venous thrombosis is a blood clot that forms within a vein. DVTs form in the deep veins of the legs, and if a piece of a blood clot formed in a vein breaks off it can be transported to the right side of the heart, and from there into the lungs, also known as venothromboembolism (VTE). A retrospective study of more than 7,000 podiatry patients identified a low overall risk of VTE in podiatric surgery, suggesting that routine prophylaxis is not warranted. Intermittent pneumatic compression devices are recommended for short-term mechanical thromboprophylaxis for moderate- to high-risk perioperative surgical and hospitalized patients, especially following lower extremity trauma. Best practices involve use of simple and practical lower leg-only devices, combined with pharmacological thromboprophylaxis when medically feasible. In this case, the documentation submitted for review does not demonstrate that the patient has any risk factors for developing VTE. Moreover, surgery of the foot and ankle has a very low incidence of VTE. In sum, the peer-reviewed literature does not support the device at issue in this low risk patient undergoing ankle surgery.Final Result: The reviewers determined that the device at issue was 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: Reviewer 1, 2, and 3 are board certified in orthopedic surgery 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: A female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) (CPT 90868). Findings:  The physician reviewer found that TMS therapy provided was not and is not medically necessary for treatment of the patients major depressive disorder. TMS is endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. According to studies, the standard regimen is treatment courses up to six weeks in duration. The authors stated that Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The authors suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. In this case, the patient started TMS therapy and had already utilized this additional time frame. At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. In sum, based on the documentation provided in context of the relevant literature and practice standards, the TMS services provided from the date of service in question, forward, were not and are not medically necessary for treatment of the patients major depressive disorder. 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 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

A 57-year-old female enrollee has requested Enbrel 50mg twice a week for the treatment of her autoimmune inner ear disease (AIED). Findings:  Two physician reviewers found that the Health Plan has apparently acknowledged the appropriateness of using biologic agents including Humira and Enbrel to treat this patients illness. At issue now is whether the proposed dosing of Enbrel is likely to have greater efficacy for this patient than standard therapies. The patient and her physician report that Enbrel 50mg twice weekly has been clearly more effective than standard dosing. Based on this finding, the increased dose of Enbrel has already proven to be more effective than standard therapies for this patients illness. Accordingly, there is sufficient evidence of the benefit of twice daily 50mg Enbrel to support its use in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 1.2 g. Based on the available documentation, this patient has normal stature which is not more than two standard deviations below the mean for age and gender, a normal bone age, and a normal adult height prediction that falls within two standard deviations of his genetic target height. He has no known morphological abnormalities of his pituitary gland. The fact that he had a suboptimal response to provocative GH testing does not support a diagnosis of GH deficiency, as such tests have poor specificity for the diagnosis of GH deficiency when performed with sex steroid priming in a child during the peri-pubertal period. Thus, the requested Nutropin AQ NuSpine 1.2 g is not supported as medically necessary for treatment of this 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 pediatrics with sub-specialty certification in pediatric endocrinology 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.