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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenNEXT (CPT 81445) and ThyraMIR (CPT 81479) genetic testing.There is sufficient support for the services at issue in this clinical setting. When a fine needle aspiration of a suspicious thyroid nodule does not reveal definitive pathology, one option is to continue to follow the lesion and re-biopsy it in the future. The other option, depending on the level of suspicion, is to send the tissue for mutational analysis. Sending the tissue for molecular analysis is an accepted and reasonable step. Labourier and colleagues noted a negative predictive value over 90% with a positive predictive value for malignancy of 82%. Thus, the test is useful in deciding whether surgery is needed. Therefore, ThyGenNEXT (CPT 81445) and ThyraMIR (CPT 81479) genetic testing were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in medical oncology, 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 magnetic resonance imaging (MRI) of the jaw and Botox injections to the jaw.The current, well accepted, universally performed test to identify the presence or absence of TMD is a comprehensive evaluation of the patients history and clinical examination and when indicated, select imaging, such as MRI. Additionally, Khawaja and colleagues state, There are conflicting reports in the literature regarding the efficacy, safety, and predictors of therapeutic response to botulinum toxin type A therapy for management of refractory masticatory muscle pain. Given this patients clinical findings, an MRI is medically appropriate to evaluate her TMJ. An MRI in open and closed mouth positions is medically appropriate when evaluating for internal derangement. It provides the most information regarding the soft tissue structures and disk position. However, there is insufficient documentation to support the use of Botox for the treatment of her TMD symptoms. Therefore, the MRI of the jaw is medically necessary for the evaluation of the patients medical condition. However, the Botox injections to the jaw are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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

A 38-year-old female enrollee has requested authorization and coverage for weekly individual counseling for treatment of the enrollees postpartum depression. Findings:  The physician reviewer found that evidence based psychotherapies such as interpersonal therapy and cognitive behavioral therapy are first line treatments for depression, per the American Psychiatric Association (APA) Clinical Practice Guideline.  Current practice in this country is focused on aggressive treatment of depression with psychotherapy, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  The frequency of sessions is negotiable based on case specifics.  Per the APA guideline, [t]he optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. Postpartum depression often goes unidentified and undertreated leading to negative consequences for women, children, men and society in general. (Berga, et al.) Combining this generality with the significant risk factors unique to this case generates the possibility of a negative outcome. A time-limited course of evidence-based individual psychotherapy on a weekly basis is safe, appropriate and consistent with good medical practice in this country as it is supported by current practice guidelines.  Accordingly, the requested weekly individual counseling is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested Aciphex 20mg for the treatment of her GERD, hiatial hernia, and ulcerative esophagitis. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to fight acid suppression, providing excellent relief of symptoms and healing to erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Inter-patient variability of the efficacy has been seen. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant or differences in their effects with regards to clinical or endoscopic end points or side effects profile.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested a DynaSplint System ankle device for treatment of his ankle pain status post left peroneal reconstruction. Findings:  Three physician reviewers found that the available peer reviewed medical literature indicates that candidates for usage of the DynaSplint System include those patients who are recovering from injury or surgery, ideally during the early phases of healing or within 100 days from date of injury, trauma, or surgery. Based on the documentation provided, this patient has had chronic ankle pain for quite some time and underwent surgery more than 100 days ago. Further, there is a paucity of available peer reviewed medical literature documenting the efficacy of the DynaSplint System for treatment of peroneal tendonopathy of the ankle. Most of the studies published to date involve use of the device in other parts of the body. Given the paucity of available literature and that the patient is more than 100 days post surgery, there is no evidence that the DynaSplint System would be as or more effective for treatment of his peroneal tendonopathy than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 10-year-old female enrollee has requested an array CGH analysis for the treatment of the enrollees global developmental delay, hypotonia, macrocephaly, seizure disorder, hypermobility and mildly dysmorphic features. Findings:  Three physician reviewers found that this patient has undergone an extensive and thorough evaluation in an attempt to put a name/diagnosis on her collection of symptoms. The proposed array CGH test is not likely to be clinically useful in this setting. There are no significant studies demonstrating it is beneficial in cases such as this, and there is only anecdotal information regarding the possible usefulness of the test.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested continued occupational therapy for treatment of his left distal humerus fracture status post ORIF.  Findings:  The physician reviewer found that compliance with an appropriate home program is expected to be a more significant factor in optimizing outcomes over regular, ongoing formal therapy given his needs to perform his exercises and on a regular basis in order to improve his range of motion and function. There is no proven significant, sustained benefit of formal passive modalities at this stage with respect to health or functional outcomes for this condition over palliative modalities that can be independently by the patient at home. The patient can perform his exercises and consult the provider every few weeks for adjustments to his home program as needed. Therefore, the requested occupational therapy services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ajovy. According to the American Headache Society (AHS), four injectable preventive therapies are available for the treatment of chronic migraine including Botox and three monoclonal antibody targeting calcitonin gene-related peptide (CGRP) or the CGRP receptor. Ajovy is a monoclonal antibody that targets CGRP that is U.S. Food and Drug Administration (FDA) approved for episodic and chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages that injectable therapies have in common. CGRP monoclonal antibodies are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3, randomized, placebo-controlled trials. Robbins and colleagues found that more patients reported constipation with Emgality than Ajovy. In this case, the patient has a history of chronic migraines that did not respond to multiple oral preventative medications. She meets the AHS criteria for continuation of CGRP monoclonal antibody therapy. The use of Ajovy has been effective in decreasing the frequency and severity of the patients migraines for the past 15 months. Given this support, the requested Ajovy is medically necessary for treatment of this patient. 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 neurology 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: Urgent Care
Decision: Overturned

A 30-year-old male enrollee has requested  psychiatric services for treatment of his psychiatric emergency medical condition.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient had a psychiatric emergency medical condition that required the services at issue on an emergent basis. Based on the documentation submitted for review, this patient presented with an acute psychotic episode with paranoia and persecutory delusions. The patients psychiatrist described an individual that posed an immediate danger to himself and others who was unable to provide adequate self-care at the time. Based on the documentation provided including the longitudinal history, the patient did have a psychiatric emergency medical condition that required the services provided from the time period specified.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested one on one speech therapy at the frequency of twice per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that children with speech delay can be readily and successfully treated (Law, et al). Goorhuis-Brouwer and Kniff specifically dealt with speech-delayed children, such as this cognitively normal patient, and pointed out that such normal children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, most often required and subsequently benefited from speech therapy (Emanuel, et al; Buschman, et al).   Speech therapy is medically indicated for this child.  The medical community standard for a near three year-old verbally delayed patient, who is functioning at approximately an 18-month level, is to continue speech therapy.  The requested two hours per week of speech therapy is medically necessary, with re-evaluation at six month intervals. If the child demonstrates improvement, but still has significant delays in expressive speech, therapy should be continued for an additional six months.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested Avastin for treatment of her metastatic non-small cell lung carcinoma. Findings:  Two physician reviewers found that Avastin is indicated in the frontline treatment of metastatic lung cancer in combination with carboplatin and Taxol. In this patients case, it is not first line treatment. While Avastin has been used in the treatment of high-grade brain tumors, there is no evidence to support its use in progressive brain metastases from non-small cell lung cancer. Additionally, Avastin can be associated with possibly life-threatening toxicities, including bleeding, clotting and abdominal perforation. The risks of Avastin in this particular case outweigh any potential benefit, which based on available scientific data remains speculative at best.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Molecular Pathology.Findings:  The physician reviewer found that In all cases, the genetic mutations that are present with pancreatic cancer can provide prognostic significance and can help direct therapy. Mutational analysis is part of the algorithms that are included within the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for pancreatic cancer. According to the NCCN guidelines, germline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. The guidelines recommend genetic counseling for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status. For example, BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. NCCN guidelines also state that tumor/somatic gene profiling is recommended for patients with locally advanced/metastatic disease were candidates for anticancer therapy to identify uncommon mutations. The guidelines state that providers should consider specifically testing for actionable somatic findings including, but not limited to fusions (ALK, NRG1, and TRK, ROS 1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and mismatch repair (MMR) deficiency. In this case, a Guardant mutational analysis was ordered to inform next steps in therapy. The patient will be offered something off-label or a phase I/II clinical trial, but with the results from molecular profiling there may be a rational selection of the next regimen. Therefore, the requested Molecular Pathology is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Findings: Two out of three physician reviewers found that the requested molecular pathology is likely to be more beneficial than any other available standard treatments for the patients medical condition.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in medical oncology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 female enrollee requested a positional MRI for medical evaluation of her rectocele.  Findings:  Two physician reviewers found that this patient has clinical symptoms which may be related to rectocele or pelvic mass encroaching on the rectum.  In this patients case, the most beneficial modality was the positional MRI of the pelvis which allowed for the evaluation of possible rectocele and evaluation for a potential pelvic/perineal mass.  All told, the positional MRI was likely to have been of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for acupuncture services, three times per month.Acupuncture applied to tender points appears to have beneficial effects on neck and shoulder pain and stiffness. Moreover, Vickers and colleagues concluded that acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. In this case, the patient has chronic neck pain with a history of anxiety and depression. The patient has received acupuncture in the past, with positive improvement. The provider reported that acupuncture has been the only treatment that helps the patient. Therefore, acupuncture services three times per month are medically necessary for the treatment of the patients medical condition.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 oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested chemotherapy regimen for treatment of her breast cancer. Findings:  The physician reviewer found that the issue in this case is whether additional cycles of Taxotere and Cytoxan (more than 4) are warranted given this patients initial characteristics. To date, there is a paucity of data to support the safety and effectiveness of treating patients with breast cancer with more than four cycles of Taxotere and Cytoxan. Thus, the patient should complete her systematic treatment with anti-hormonal therapy and is expected to complete local treatment. There is reported positive health outcomes with Taxotere and Cytoxan,  with researchers only administered four cycles of therapy and offered results based upon those cycles (Jones and colleagues). Therefore, at this juncture, there is inadequate evidence to support additional cycles of Taxotere and Cytoxan in the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female has requested Nutropin for treatment of her short stature.    Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of Nutropin in this patients case.  This patients height is 2.6 standard deviations below normal for age and gender, and her growth velocity is suboptimal for mid-puberty.  The patients bone age was 11 years at a chronological age of 11 years 5 months.  Based on her bone age assessments over a five-month period, the estimated final adult height prediction is approximately 57 inches.  This adult height prediction is 3 standard deviations below normal.  Although this patient had normal IGF-1 and IGFBP-3 levels and normal results on provocative growth hormone testing, a subtle defect in the growth hormone/IGF-1 axis is likely, and other causes of short stature have been ruled out.  In this clinical setting, a trial of growth hormone therapy is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a hyaluronan injection in each knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments. Therefore, the requested hyaluronan injection in each knee is medically necessary for the patients medical condition.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.