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

A 26-year-old female enrollee has requested cryoablation for treatment of her fibroadenoma in the right breast.  Findings:  Two physician reviewers found that the peer-reviewed medical literature indicates that fibroadenomas, although benign, can cause physical deformity, discomfort, and emotional distress. Conventional management options include observation and surgical excision. Cryoablation is a newer treatment approach that is a minimally invasive office based procedure that is administered without the use of general anesthesia (Kaufman, et al). Currently, the evidence supporting the safety and efficacy of cryoablation is based on case series and a registry report. Overall, there is inadequate published data demonstrating improved health outcomes with cryoablation versus standard surgical excision. Thus, the requested cryoablation procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old man who was referred for evaluation due to long-standing problems with focusing, procrastination, reading, distractibility with difficulty staying on topic when talking with people, and poor organizational skills. He also noted a habit of biting his nails, playing with his hands, and eating when stressed. The patient tended to obsess over things such as his weight or playing computer games for long hours. By the end of his evaluation, inclusive of the SPECT and CT scans, he was diagnosed with rule out attention deficit hyperactivity disorder (ADHD), depression  not otherwise specified, and generalized anxiety disorder. Recommendations for treatment included Wellbutrin, Lexapro and Adderall.At issue is whether the SPECT and CT scans were medically necessary for evaluation of the patients medical condition.There is nothing about the patients history or clinical exam that mandated a SPECT or CT scan in order to formulate a meaningful differential diagnosis. Based upon the clinical information available prior to the SPECT and CT scans, there was an array of standard treatments available, which could have afforded the patient relief. The SPECT and CT scans added no clinical value in the diagnosis and management of this patients condition. Therefore, I have determined the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees autism spectrum disorder.Findings:  Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine/gross motor skills and processing of sensory and motor information are also common. There are many potential etiologies, as well as many suspected risk factors and associations, with clinical symptoms being the final common denominator. Many approaches have been used to facilitate development of adequate communication and interpersonal skills in these children. Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy.While there is some evidence to support genetic testing of children with autism, the constellation of tests recommended for this patient is not currently considered clinically useful as a screening tool for metabolic and/or immunologic abnormalities. Should he exhibit the clinical profile of a child with immunodeficiency, immune lab testing would be indicated. Should he have a clinical presentation suspicious for encephalitis, laboratory evaluation including lumbar puncture and imaging would be indicated. Until this type of laboratory interrogation has been demonstrated to be useful in patients with autism and/or developmental regression, the laboratory testing was not likely to have been superior over the standard evaluations available for this patient.Final Result: Two of the three reviewers determined that the services at issue were 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:  One of the three reviewers is board certified in pediatrics with expertise in child neurology and is actively practicing. Two of the three reviewers is board certified in neurology with special qualifications in child neurology. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an annual pap smear. Researchers concluded that among older women, five-yearly screening is approximately as efficacious as more frequent screening. The U.S. Preventive Services Task Force lists multiple recommendations for cervical cancer screening for patients aged 30 to 65 with normal results. These recommendations include a pap test every three years, HPV testing every five years, or co-testing (pap test and HPV testing) every five years. In this case, the patient does not have a history of abnormal pap smears. For such patients with normal prior history, the medical literature specifies an interval of no sooner than every three years for routine cervical cancer screening. Therefore, an annual pap smear is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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: The patient has requested authorization and coverage for epidural corticosteroid injection of the lumbar spine. Findings:  The physician reviewer found that At issue is whether the requested epidural corticosteroid injection of the lumbar spine is medically necessary for treatment of this patient. The American Society of Interventional Pain Physicians (ASIPP) have published guidelines on the use of epidural interventions for treatment of patients with chronic spinal pain .The authors noted that, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. A systematic review from Fang and colleagues evaluated the clinical efficacy of epidural injections with or without steroids in the treatment of patients with pain due to degenerative disc disease. The authors found that the addition of steroids to local anesthetic was associated with superior Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) scores when compared to treatment with local anesthetic alone within one year in patients with degenerative disc disease. In this case, the patient has chronic low back pain with radiation into the right lower extremity since at least 2018 with recurrent episode. The patients lumbar magnetic resonance imaging (MRI) confirmed the presence of neuroforaminal stenosis at L4-5 and L5-S1 consistent with this presentation. The provider reported that the patients condition has been refractory to medication management despite treatment from a variety of different drug classes. The provider recommended an epidural steroid injection to provide relief of the patients radicular symptoms. Overall, the medical literature and current guidelines support the requested epidural corticosteroid injection of the lumbar spine to treat this patients lumbar radiculopathy due to degenerative disc and joint disease. Therefore, the requested epidural corticosteroid injection of the lumbar spine is medically necessary for treatment of this patient.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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stretta radiofrequency ablation. Findings:  The physician reviewer found that review of the current medical literature and guidelines, Stretta radiofrequency ablation is not supported as likely to be more beneficial than any standard therapy for treatment of this patients gastroesophageal reflux disease (GERD) symptoms. A systematic review to evaluate the evidence on the efficacy of Stretta for the management of GERD did not show any benefit of Stretta over placebo or medical therapy (Lipka, et al.). A recent review on the available studies on Stretta concluded that, high-quality randomized trials are warranted to address the controversy generated by analysis of randomized trials of Stretta (Nabi, et al.). Furthermore, the current American College of Gastroenterology (ACG) guidelines for the treatment of GERD do not recommend Stretta in lieu of standard procedures (Katz, et al.). The ACG noted that, Because data on the efficacy of radiofrequency energy (Stretta) as an antireflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies. Given these findings, the requested Stretta radiofrequency ablation is not 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 requested Stretta radiofrequency ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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

The patients parent has requested reimbursement for self-determination therapy (SDT) services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week) and prospective authorization and coverage for future SDT services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week). There are several established treatments for autism spectrum disorder. The National Autism Center has identified applied behavior analysis (ABA), and other behavioral interventions, as the most effective treatment modalities for patients with autism. In this clinical setting, the most effective treatments have been identified to be behavioral in nature, including behavioral and cognitive behavior therapy, and behavior activation therapy. However, SDT is not included in the recommendations for patients with autism. Researchers found that SDT is the only theory of motivation that explicitly identifies autonomy as a human need, that, when supported, facilitates more autonomous forms of behavioral regulation. The current data highlights that SDT is a lens to identify motivation that may affect treatment effectiveness, but is not an applied treatment. All told, the SDT services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week) and future SDT services (five days per week, 2.5 hours per day) and SDT supervision services (three hours per week) were not and are not medically necessary for treatment of this patient. 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 a B.C.B.A, board certified in psychology, 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 56-year-old female enrollee has requested a CT scan of the heart for an evaluation of her atypical chest pain and labile hypertension. Findings:  The physician reviewer found that CT angiography (CTA) and electron beam computerized tomography (EBCT) are not accepted screening or confirmatory tests for the diagnosis of coronary artery disease in this patient subset and are not medically acceptable replacements for other conventional screening tests within the standard of care, such as treadmill stress testing. CTA is also not a medically acceptable substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CT scan of the heart in the diagnosis and prognosis of coronary disease in this subset currently remains an experimental application of this technology. The Health Plans denial is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio infusions every four weeks. Findings: In the randomized placebo-controlled GEMINI I and II trials, patients with ulcerative colitis or Crohns disease who failed to achieve remission by week six continued Entyvio every four weeks rather than every eight weeks with satisfactory results. Additional studies have demonstrated the safety and efficacy of Entyvio for both induction and maintenance of remission, with remission in over 40% of patients after one year. In this case, the patient has demonstrated signs and symptoms consistent with active disease given the report of two to three bowel movements per day with bleeding and urgency. The patients laboratory testing revealed anemia as well as a low Entyvio level. Continuation of Entyvio dosed at every eight weeks would place the patient at risk for complications of partially untreated ulcerative colitis. For these reasons, the requested Entyvio infusions every four weeks are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 subspecialty 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

An enrollee has requested authorization and coverage for Epogen solution 20,000 unit/mL.The current medical evidence does not support the requested medication in this clinical setting. Most experts administer Epogen for a hemoglobin of less than 10. In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESA) to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines state that the potential benefits of reducing blood transfusions and anemia-related symptoms should be balanced against the harm in individual patients (such as stroke, vascular access loss, and hypertension). In this case, the patient's hemoglobin has improved to 11.3, which exceeds 11 g/dL, the level above which patients were found to experience greater risks for death, serious adverse cardiovascular reactions, and stroke in controlled trials. Under these circumstances, Epogen solution 20,000 unit/mL is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in hematology and 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: Upheld

The patient has requested authorization and coverage for double mastectomy. A mastectomy, defined as the complete removal of the breast tissue, is a surgical option for patients diagnosed with breast cancer as well as a prophylaxis to reduce the risk of breast cancer in high-risk women, a study found that, prophylactic mastectomy generally occurs in two different patient populations: (1) high-risk women without breast cancer who undergo bilateral prophylactic mastectomy (BPM) to reduce their risk of developing breast cancer and (2) women with unilateral breast cancer who choose contralateral prophylactic mastectomy (CPM) to prevent cancer in the contralateral breast. Most studies conclude that BPM is not indicated for women without quantifiable high-risk demonstrated with a strong family history and/or findings on breast biopsy known to increase risk of future invasive cancer such as atypical hyperplasia or lobular carcinoma in situ. Alternative strategies for managing high-risk patients include rigorous surveillance with clinical breast examinations, mammography, and potentially breast MRI, endocrine therapy, and lifestyle changes. Final Result: The reviewer determined that the requested services 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 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested the allograft placement for medical treatment of her burns on the bilateral feet and lower extremities. Findings:  Two physician reviewers found that the patient sustained wounds which would be considered not only serious but potentially life threatening. Excision and coverage of the devitalized tissue was appropriate to reduce the risk of infection. When skin grafting is either not possible or is not an option, an allograft is a reasonable and recognized treatment option in attempts to prevent sepsis. The allograft placement was likely to have been more beneficial for treatment of this patients medical condition than any available therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested removal of a chest wall tumor for treatment of her chest wall mass.   Findings:  The physician reviewer found that the differential diagnosis in this patients lesion is angiolipoma causing pain and recent growth, a lipoma with recent growth and pressure effect on an intercostals nerve causing pain, or a neurofibroma associated with pain. For any of these diagnoses, the appropriate treatment includes simple excision of the mass lesion, which can be done with local anesthesia in an ambulatory setting. Therefore, the patients request for excision of this mass lesion is medically necessary to establish diagnosis and also relieve patients symptoms.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested a laparoscopic duodenal switch for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a body mass index (BMI) of 47. The duodenal switch operation is an established operation with proven superior outcomes data. These measures include not only the excess weight loss, but also resolution of comorbid conditions. Published data demonstrate less excess weight loss with the lap band procedure and gastric bypass. It also shows higher complication rates of reflux and dysphagia. The laparoscopic duodenal switch procedure is medically appropriate in this setting and is indicated for treatment of this patient.