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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA genetic panel testing.According to the National Comprehensive Cancer Network (NCCN) criteria for genetic testing for hereditary breast and ovarian cancer, at least one of the following should be met: personal history of breast cancer diagnosed at or before 45 years of age; personal history of breast cancer between age 46 and 50 with unknown or limited family history, or second breast cancer diagnosed at any age, or one or more relatives with breast, ovarian, pancreatic or prostate cancer; personal history of triple negative breast cancer diagnosed before 60 years of age; personal history of breast cancer at any age and one close relative with ovarian cancer, metastatic prostate cancer, pancreatic cancer or breast cancer diagnosed at 50 years of age or younger; personal history of ovarian cancer at any age; personal history of exocrine pancreatic cancer at any age.In this patients case, the NCCN criteria were not met. She was diagnosed with breast cancer at age 63. The records noted a family history of colon cancer. Based on the submitted clinical documentation, the patient does not meet criteria to qualify for the BRCA gene panel testing. Given the patients age of diagnosis and absence of family history of relevant cancers (ovarian, pancreatic and prostate), the probability of hereditary predisposition is low. Therefore, the requested BRCA genetic panel testing is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in clinical genetics and genomics 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 reimbursement for BRAF mutation analysis gene panel testing.Findings:  Two of the three physician reviewers found that the medical evidence has not demonstrated the superior effectiveness of the services at issue. Per the literature, BRAF mutation analysis gene panel testing (Afirma Thyroid FNA Analysis) was not likely to have been superior to cytology interpretation of pathologic thyroid specimens. A study reported that the rate of malignancy in thyroid nodules suspicious by Afirma was 18.3% while the rate of malignancy in nodules suspicious for neoplasm on cytology interpretation was 31.2%, resulting in a false positive rate of 56%. The authors concluded that cytology interpretation has a higher rate of predicting malignancy when compared with the Afirma test, by almost twofold. Sacks and colleagues reported increased incidence of indeterminate fine needle aspiration diagnoses after Afirma became routinely available, whereas the incidence of benign diagnoses significantly decreased. The authors noted that Afirma raised uncertainty of the benefits of molecular testing and may produce unintended collateral effects, increasing the number of indeterminate fine needle aspiration diagnoses while not affecting the institutional thyroidectomy rate or malignancy yield. Thus, BRAF mutation analysis gene panel testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to have been 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 1, 2 and 3 are board certified in clinical genetics and genomics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female who experienced traumatic brain injury as the result of a fall from a horse in May 2004. In addition, the patient was previously diagnosed with multiple sclerosis. Following the injury the patient received neurobehavioral rehabilitation services on a 14-day referral. The patient was subsequently readmitted to residential care. The patient remains severely impaired. The patients representative has requested authorization and coverage for additional neurobehavioral cognitive services. The Health Plan has denied authorization for the requested services on the basis that additional neurobehavioral cognitive services are not medically necessary for treatment of the patients medical condition.Review of the submitted materials indicates the patients rehabilitation team believes the patient is appropriate for discharge to outpatient therapy and no longer requires inpatient rehabilitation. The patient did not make significant gains as a result of previous neurobehavioral cognitive services. There is no evidence that additional neurobehavioral cognitive services are likely to result in improvement in the patients cognitive abilities. Ongoing outpatient rehabilitation services appear to be medically appropriate. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Rozerem 8 mg, three tablets at bedtime, for treatment of his insomnia. The physician reviewer found that per the medical evidence, patients with insomnia should receive therapy for any psychiatric illness, medical condition, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia.  For patients with continued symptoms which require intervention, cognitive behavioral therapy is the initial therapy that is recommended.  If a patient requires a combination of behavioral therapy and medication, a short-acting medication is recommended for six to eight weeks and then tapered.  If symptoms continue, an evaluation in a sleep disorder center prior to the institution of long-term medications is appropriate.  Rozerem is a hypnotic medication that is a melatonin receptor agonist, and the FDA has approved the dosage of Rozerem 8 mg to be taken within 30 minutes of bedtime.  It is approved for treatment of insomnia characterized by difficulty with sleep onset.  In this case, the documentation notes that Rozerem 8 mg is not an effective dose for this patients insomnia.  There is no documentation available to show that the patient has received sufficient treatment for any medical or psychiatric conditions contributing to his insomnia.  Additionally, the records do not document medical reasons why this patient should receive a non-FDA approved dose of Rozerem for insomnia.  All told, Rozerem 8 mg, three tablets at bedtime is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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 parent of an enrollee has requested authorization and coverage for a baby scale.  Failure to thrive generally refers to growth below the percentile, or crossing of two major percentiles over a short period of time. The etiology may be organic or psychosocial, or a combination of both. The list of organic causes of failure to thrive is quite long, and includes gastroesophageal reflux disease, metabolic disorders, and chromosomal disorders, all of which were under consideration in this case.  Hospitalization is indicated in cases of severe malnutrition. Goals of hospitalization include identification, if possible, of etiology, formulation of an appropriate feeding strategy with demonstrated pattern of weight gain, and correction of any metabolic derangements. Family education is also essential. Early identification and treatment of failure to thrive are essential to prevent the substantial complications that would otherwise arise.In this patients case, she had evolving evidence of gastrointestinal issues, and was ultimately diagnosed with food protein induced enterocolitis syndrome. With the exception of the letter from the provider, there was no mention of failure to thrive in the clinic notes. The patient was described as healthy and thriving. While weighing the patient before and after meals may have initially been appropriate to determine how much breastmilk she was actually receiving, at her current age, such close monitoring is not indicated. It would be reasonable to monitor the patients weight gain progress with weekly clinic visits or possibly a nutrition consultation. All told, the requested baby scale is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested equipment 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 pediatrics 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

The patient is a 16-year-old female with a long-standing history of behavioral and depressive symptoms. She has had three suicide attempts, high anxiety, much family strife, and trichotillomania. She is also experiencing problems in school, is overweight, and has chronic migraines and many personality conflicts. She remains mildly to moderately depressed on Klonopin, Geodon, Prozac, Wellbutrin, Topamax, and Relpax. She also has many somatic problems.  The patient was admitted to a psychiatric residential treatment program on 1/24/05. The Health Plan indicates residential treatment services were not medically necessary as of 4/12/05. The patient has long-standing problems, has not done well in prior outpatient treatment, and resides in an area with a clear paucity of adolescent treatment facilities (e.g. a partial hospitalization program or appropriate range of skilled professionals).  While the patient seems to have gradually improved in her depression, clear Axis II issues remained as of 4/12/05 and the patient required further structured and intense treatment. Such treatment was best obtained in her current residential treatment center facility and the clinical evidence indicates the patient was beginning to improve. Though she does not appear to have been suicidal or psychotic as of 4/12/05, the patient was not appropriate for discharge at that time. Standard of care would be to ensure an appropriate transition to a less intense level of care. In light of the patients history and clinical condition as of 4/12/05, an additional six weeks of residential treatment beyond 4/12/05 is medically appropriate and indicated to ensure stabilization and appropriate transition to a less intense level of care. The patient should be fully re-evaluated at the end of the six-week period to determine if she has been stabilized and is appropriate for discharge.Based upon the information set forth above, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for laboratory testing for evaluation of ulcerative proctitis/left sided colitis. Findings:  Two physician reviewers found that there is a lack of sufficient medical evidence to support the effectiveness of the services at issue when compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels.  It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control.  Moreover, controlled studies are lacking to show that use of the test results in improved long term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, there is not sufficient evidence from controlled studies to definitively demonstrate that the laboratory testing was likely to have been more beneficial than any available standard therapy for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 27 hours per week of one-on-one applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that according to a study  Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD). This research studied 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In addition, several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes . In this case, the patient has made progress in many areas, but he continues to demonstrate significant delays in adaptive skillsets, tantrums with self-injury as well as spitting and smearing of saliva. The patient has recently demonstrated a significant increase in tantrums and self-injury behaviors. Based on the documentation submitted for review, the request for 27 hours per week of one-on-one ABA therapy is medically necessary for treatment of the patients autism spectrum disorder.  Final Result: The reviewers 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: Physician reviewer number two is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 authorization and coverage for substance abuse intensive outpatient program (IOP) treatment services. Findings:  The physician reviewer found that there were no emotional, behavioral, cognitive, or impulsive issues that would prevent treatment at the outpatient level of care. The patient is not gravely disabled and has been motivated and engaged in treatment. The patient's home environment is supportive and without alcohol present. The patient's post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and sleep disturbance did not require monitoring or treatment at IOP level of care. The patient was appropriate for step down to outpatient counseling. 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 psychiatry with sub-specialty certification 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: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested for speech therapy for treatment of the enrollee, who has developmental delays. Findings:  The physician reviewer found that the most pronounced deficiency was noted with the EOWPVT, an evaluation designed to assess English speaking vocabulary and verbal intelligence, allowing the examiner to screen for school readiness or estimate the English fluency of bilingual individuals. The current assessment does not differentiate between delays due to a bilingual upbringing and a true language delay. All told, the medical necessity of the requested speech therapy at this time has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eighteen year-old male who sustained a neck injury and underwent C5-6 anterior discectomy with instrumented fusion is requesting reimbursement for the cost of the bone growth stimulator.  Reviewers Findings: The reviewing physician found that the use of a bone growth stimulator was not warranted in this clinical situation.  The physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser/IPL treatment skin greater than 500 square centimeters. According to the current medical literature, laser treatment or intense pulsed light (IPL) would be expected to improvement the telangiectasias of rosacea, but not the inflammatory component. As the requested services will not address the patients problematic symptoms, the requested services are not supported as medically necessary. With regard to the whether the service should be provided as a reconstructive procedure, the patient presents with an abnormal condition related to disease. However, there is a lack of documentation of a functional limitation associated with this abnormal condition. The requested treatment is expected to improve the telangiectatic component of rosacea, which is mainly considered a cosmetic concern. Moreover, the treatment is not likely to provide a more than minimal improvement in the patients appearance. Thus, the requested laser/IPL treatment skin greater than 500 square centimeters is not supported as reconstructive in nature. 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 dermatology 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 60-year-old female enrollee has requested Cymbalta 60mg, three capsules per day for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication dosage in this patients case.  The United States Food and Drug Administration (FDA) provides medication dose recommendations based on scientific data.  The interpretation and application of these recommendations falls upon clinicians working directly with the patient population.  There is insufficient medical evidence supporting the requested medication dosage in this patients case.  There is a lack of well-designed studies, case series or trials in the peer-reviewed literature demonstrating the effectiveness of Cymbalta at a dose of 180mg daily.  Further, per the documentation provided, the patient has not exhausted standard therapies, such as alternative antidepressant medications or evidence-based augmentative strategies and psychotherapy, used in the treatment of major depressive disorder.  All told, Cymbalta 60mg, three capsules per day, is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested point-stimulation (P-Stim) therapy for medical treatment of her fibromyalgia.  Findings:  Two physician reviewers found that the patient is being treated for chronic pain with a diagnosis of fibromyalgia which is a disorder which typically has significant psychological components, particularly depression and other affective problems.  This type of electrostimulation is being evaluated for a variety of conditions, including pain, depression, and anxiety.  It is not a recommended treatment as the evidence is insufficient to evaluate the effect of auricular electroacupuncture on acute and chronic pain.  All told, the requested P-Stim therapy is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for in-home international normalized ratio (INR) monitoring device (CPT G0249). The records provided for review document that this patient presents with a history of factor V Leiden, MTHFR, and prothrombin gene mutations. The patient has been treated with anticoagulant therapy since diagnosis with DVT and pulmonary embolism in 2012. The provider has recommended use of an in-home INR monitoring device. As noted in the medical literature, self-monitoring is not feasible for all patients and requires patient education and demonstrated ability to use the device. Phibbs and colleagues reported that in their study of 3,643 patients, 80% of patients were able to demonstrate competency in using an in-home INR monitoring device. In-home INR testing has been shown to be more effective and convenient for patients who require frequent monitoring. Moreover, patient self-testing at home compares favorably with the results achieved in randomized trials or in anticoagulation clinic settings. Given these findings, the requested in-home INR monitoring device (CPT G0249) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.