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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a series of Euflexxa injections to the left knee. Findings:  The physician reviewer found that medical literature pertaining to viscosupplemention 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 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. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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, there is a history of failed arthroscopic surgery, ice, rest, corticosteroid injections, and the patient is not a candidate for total knee arthroplasty because of age and the absence of severe arthritis necessary for such a procedure. Under these circumstances, viscosupplementation is necessary for pain relief. Accordingly, the requested series of Euflexxa injections to the left knee is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 57-year-old female enrollee has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that the documentation does not support the medical necessity of the requested PT services for treatment of this patients foot and ankle pain as well as the right shoulder. The guidelines of PT practice support an initial evaluation, daily treatment notes, and periodic reassessments to support the efficacy of interventions. There should be an initial evaluation which supports the need for therapy. The documentation does not reveal clinical documentation by the providers revealed deficits that require continued skilled PT. The notes from the provider reveals the patient has improved ADLs, no significant pain or discomfort, and has improved strength. There are no physical examination deficits of the foot that require skilled therapy. The documentation does not reveal a treatment plan or evaluation prior to the most recently requested therapy indicating a plan of care or deficits that require skilled therapy for either the shoulder or the foot. Given these findings, the requested PT is not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 authorization and coverage for exome sequencing testing (CPT 81415). The provider caring for this patient has recommended whole exome sequencing (WES) for diagnostic purposes given the constellation of symptoms including enamel hypoplasia, eczema, vitiligo, xerosis, and skin hypopigmentation. In contrast to current sequencing tests that analyze one gene or small groups of related genes, WES will analyze the exons or coding regions of over 20,000 genes. Therefore, sequencing the exome is an effective method of analyzing the patients DNA to discover the genetic cause of diseases or disabilities. Researchers found that of 100 families with 119 children affected by neurodevelopmental disorders, WES led to a diagnoses leading to a change in the clinical care or impression of the pathophysiology in 49% of newly diagnosed families. Similar findings have been reported by another study, which noted that WES yielded a presumptive diagnostic rate of 41% in patients with neurodevelopmental disabilities and unrevealing work-up. Moreover, the American College of Medical Genetics and Genomics supports the use of WES in this patients clinical setting. As noted, the patient has undergone a robust genetic evaluation of all know genes associated with ectodermal hypoplasia, which failed to identify a unifying diagnosis. All told, the requested exome sequencing testing (CPT 81415) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested exome sequencing testing (CPT 81415) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer  is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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 epidural steroid injections for treatment of her medical condition.  Findings: The physician reviewer found that in this case, the patient has been treated with physical therapy previously. However, there is a lack of documentation of a new course of therapy and home exercise program. The current medical literature indicates that a home exercise program after physical therapy independent of epidural steroid injections can give patient lasting results (Van Zundert, et al). Moreover, the patient does not have any recent physical exam findings supporting a diagnosis of lumbar radiculopathy (Gellhorn, et al). Given these findings, the requested epidural steroid injections were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 anesthesiology with sub-specialty 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 reimbursement for the panel of gene tests for evaluation of the enrollees malignant melanoma.  Findings:  The 3 physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis. Gene expression profiling for melanoma could be a valuable contribution to understanding the biology of the disease. However, the difficulty of embracing gene expression profiling as an independent predictor of outcome is illustrated by the inconsistency of results across studies aimed at defining the most predictive gene sets for melanoma. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, it would be considered investigational/experimental for this patient. In addition, the records do not show that this patient has received standard treatment for metastatic melanoma. As such, the panel of gene tests performed were not likely to have been more effective than the standard of care for the evaluation of this patient. Final Result: The 3 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 reviewer number one is board certified in internal medicine with sub-specialty 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.Physician reviewer number two is board certified in internal medicine with sub-specialty 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.Physician reviewer number three is board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services, specifically the use of a real time heart monitor for evaluation of the enrollee who presented with premature ventricular contractions. Findings:  The physician reviewers found that the documentation provided does not support the superior efficacy of the services at issue in this clinical setting. The records provided indicate that this patient had intermittent palpitations.  In this circumstance, if additional evaluation for a dysrhythmia is thought to be necessary then prolonged serial 48 hour Holter monitoring or off line self activated or auto triggered cardiac event monitoring should be sufficient in recording cardiac rhythm during symptoms. In this patients case, the documentation did not indicate that these devices have already been tried and failed for the evaluation of his current symptoms. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient activated or auto triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Continuous real time monitoring by telemetry services is not likely to be superior since off line analysis of a patient activated or auto triggered event recorder should be sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services had exceeded what was clinically indicated in this patient. As such, the real time heart monitor was not likely to be more effective than the standard monitoring techniques for the evaluation of this patients medical condition. Final Result: Two of 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 50-year-old male enrollee has requested acute inpatient detoxification for treatment of his substance use disorder.  Findings:  The physician reviewer found that there were no noted co-morbid substance use disorders at admission in this case. He did not present as a complicated withdrawal and was noted to be sleeping on two occasions during evening rounds and did not require withdrawal prophylaxis. The patients vital signs at detoxification admission reflected an elevated pulse and blood pressure. Applying the American Society of Addiction Medicine (ASAM) criteria, this patient presented with a potential for alcohol withdrawal as his clinical institute withdrawal assessment for alcohol (CIWA-Ar) score was greater than 10 and he had tachycardic pulse rate. However, the patient was not noted to have actually experienced any withdrawal symptoms that could not have been adequately managed on an outpatient basis. Overall, detoxification in an inpatient setting was not medically necessary for this patient, and proper outpatient treatment could have been a reasonable alternative for care. In addition, inpatient rehabilitation could have also been supplanted by an outpatient rehabilitation program for alcohol dependence as no reported past inpatient or outpatient rehabilitation programs were recorded. Aversion therapy does not support evidence-based practice. As such, the medical necessity for the detoxification services and inpatient alcohol rehabilitation was not satisfied for the time period in review.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested OxyContin Extended Release 80 mg (one tablet four times per day) for medical treatment of her cervical and lumbar myofasciitis status post lumbar fusion. Findings:  Three physician reviewers found that it is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain. High dose opiates may also cause adverse outcomes and therefore the patients requested authorization and coverage for OxyContin Extended Release 80 mg is not indicated. The prescribed dose exceeds the recommended maximum dose of OxyContin 80 mg twice per day. Thus, the requested OxyContin Extended Release 80 mg (one tablet four times per day) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested water circulating cold pad with pump (HCPCS-E0218) used post-operatively for treatment of the enrollees medical condition status post left shoulder surgery.  Findings: Two physician reviewers found that the water circulating cold pad with pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Uquillas and colleagues reported on various means of controlling pain after a shoulder surgery. The authors indicate that cryotherapy can be effective, however they failed to conclude that cryotherapy is superior to other standard methods. Kraeutler and colleagues compared cryotherapy with the standard therapy of ice wrap. The authors concluded that There does not appear to be a significant benefit to use of [compressive cryotherapy] CC over standard [ice wrap] IW in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. In sum, there is a lack of medical literature supporting that the post-operative use of water circulating cold pad is superior to standard therapy such as an ice wrap. Therefore, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two 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: All three physician reviewers are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested mitochondrial electron transport chain testing for evaluation of the enrollees cyclic vomiting, hypotonia, and speech delay. Two physician reviewers found that the evaluation and treatment of mitochondrial disease was reviewed in a recent consensus statement from the Mitochondrial Medicine Society. The data demonstrates that skeletal muscle is one of the preferred tissues for doing biochemical analysis or mitochondrial DNA sequencing because tissue-specific alterations may not be present in blood. Muscle and/or liver biopsies should be performed in the routine analysis for mitochondrial disease when the diagnosis cannot be confirmed with DNA testing. This review supports the utility of biochemical studies on muscle as the standard recommendation in the evaluation of suspected mitochondrial disease. Consistent with these findings, the requested mitochondrial electron transport chain testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result:  Two reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in pediatrics and medical genetics and is actively practicing.  One reviewer is board certified in neurology, child neurology and pediatrics with a sub-specialty certification in neurodevelopmental disabilities and is actively practicing.  One reviewer is board certified in clinical genetics and clinical biochemical genetics with a sub-specialty certification in pediatrics and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested  hyperthermic extracorporeal applied tumor therapy (HEATT) clinical trial (formerly perfusion induced systemic hyperthermia (PISH)) for treatment of her stage IV ovarian cancer.  Findings:  Two physician reviewers found that in the medical literature, van der Zee and colleagues reported some efficacy on the HEATT method when given with chemotherapy. In 2013, Ahmed and Zaidi reviewed this treatment and reported improved health outcomes when used with radiation therapy and chemotherapy. The proposed treatment is a part of a Phase I clinical trial and is noted to include use of hyperthermia alone. As such, the goals of the protocol are mostly to determine dose, safety, and toxicity. Currently, there is a lack of data suggesting that the requested HEATT clinical trial (formerly perfusion induced systemic hyperthermia (PISH)) conducted by James Lilja, MD of Bay Area Gynecology Oncology Clinic at Good Samaritan Hospital in San Jose is likely to provide this patient with superior results when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested for referral to an orthopedic spine specialist for treatment of her medical condition status post motor vehicle accident.   Findings:  The physician reviewer found that it is well accepted that adequate attempts at conservative modalities (including physical therapy utilizing manipulation/mobilization techniques) are indicated before pursuing surgical intervention. In 2004, Gross and colleagues published a systematic review of randomized trials in which the authors assessed manipulation and mobilization techniques in terms of pain relief, improved function, patient satisfaction, and global perceived effect in adult patients with mechanical neck disorders. Of the 33 selected trials, 42% were high quality trials. The authors reported strong evidence of benefit favoring multimodal care including mobilization and/or manipulation plus exercise for treatment of chronic mechanical neck disorders (MND) with or without headache. In the case of this patient, while one of the patients providers states that the patient has undergone physical therapy, the submitted medical records do not include documentation of the duration and intensity of the patients course of therapy and the patients response. Objective documentation of an adequate course of physical therapy is required prior to an orthopedic evaluation for a surgical procedure.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee requested inpatient psychiatric hospital services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that hospitalization was for purposes of diagnosis, in addition to active treatment that was reasonably expected to improve the patients condition while preventing a more serious episode of illness. In addition, hospitalization was medically necessary for continued care and installation of a treatment plan aimed at mitigating the risk for readmission and reducing both psychiatric morbidity and violent behaviors in the home. In sum, the treatment setting was safe, appropriate and consistent with good medical practice. Considering the case in its entirety, and applying the current practice guidelines and relevant peer reviewed literature, it was medically necessary for the patient to have been treated at an inpatient level of care.