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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant CDx test (circulating tumor DNA test). Metastatic colon cancers should be tested for KRAS, NRAS, BRAF, HER2, and microsatellite instability (MSI) or mismatch repair (MMR). The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of colon cancer notes that such testing may be performed individually or as part of next-generation sequencing (NGS) panel. NGS panels may identify rare and actionable mutations and fusions known to have targeted therapy. Universal genetic testing is recommended on all colon cancer tumors, and an NGS panel allows for initial screening with MSI testing. However, cell-free/circulating tumor DNA testing should not be used instead of a histologic tissue diagnosis. Standards for analytical performance characteristics of cell-free tumor DNA have not been established, and in contrast to tissue-based testing, no guidelines exist regarding the recommended performance characteristics of this type of testing. The use of cell-free tumor DNA testing in colon cancer is not as well studied, unlike in the setting of non-small cell lung cancer. In this clinical setting, it is unclear how the results of such testing would change the course of the patients management given that the patients molecular markers had previously been evaluated. Therefore, the Guardant CDx test (circulating tumor DNA test) was not likely to have been more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Guardant CDx test (circulating tumor DNA test) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested facial feminization surgery for treatment of her gender dysphoria.  The physician reviewer found that per the World Professional Association for Transgender Health (WPATH) Standards of Care regarding the medical necessity of sexual reassignment surgery (SRS) including facial feminization surgery, `Professionals who provide services to patients with gender conditions understand the necessity of SRS, and concur that it is reconstructive, and as such should be reimbursed, as would any other medically necessary treatment.` The submitted documentation demonstrates that multiple providers have documented the patients longstanding history of gender dysphoria. Of particular concern to the patient is the presence of masculine facial features. The photographs provided confirm the presence of masculine facial features. A study by Ainsworth and Spiegel found that facial feminization surgery resulted in improved mental health related quality of life in male-to-female transgender individuals. As such, the proposed procedures of brow lift, frontal bossing, orbital reshaping of brow, hardware plates and screws for frontal set back procedure, rhinoplasty, septoplasty, lip augmentation and chin/jaw contouring are medically necessary for treatment of this patients gender dysphoria. These procedures also meet reconstructive surgery criteria, as the presence of the patients masculine facial features represents an abnormal structure of the body due to the patients gender dysphoria and these procedures would be expected to create a normal appearance as well as provide more than minimal improvement in the patients appearance. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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

Nature of Statutory Criteria/Case Summary  A gender-neutral enrollee has requested a reimbursement for a reduction mammoplasty. Findings:  The physician reviewer found that A gender-neutral enrollee has requested a reimbursement for a reduction mammoplasty. The Health Plan has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees gender dysphoria and were not reconstructive in nature. There is support in the medical literature for the services at issue in this clinical setting. The patient had undergone bilateral breast reduction to reduce the female appearance of the breasts in order to treat gender dysphoria. The records support that this patient had evidence of breasts that were consistent with the female gender.  The patient does not identify as either male or female. Instead, the patient  identifies as gender-neutral. As such, a female appearance of the breasts would be considered an abnormal body structure for someone who identifies as gender neutral. Based on the documentation provided, this patient has gender dysphoria associated with adult female breasts.  The patients preoperative photographs are more consistent with the female gender.  Therefore, the reduction mammoplasty was medically necessary for treatment of this patients gender dysphoria.With regards to whether the services at issue were reconstructive in nature, this patients breast development constituted an abnormal body structure for someone who identifies as gender-neutral. The patients breasts should not be consistent with adult female breasts. As such, the patients breasts can be considered a developmental abnormality for a non-binary person. The patients breast development should be more consistent with an adult non-binary person. Based on the postoperative photographs, there was a significant breast reduction which was consistent with a nipple sparing mastectomy. Reduction mammoplasty is generally performed to improve function, but may also be done to approximate a more normal appearance. Although this case does not specifically address traditional indications for breast reduction, the reduction mammoplasty offered more than a minimal improvement in this patients appearance. For these reasons, the reduction mammoplasty performed was reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition and were reconstructive in nature. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: The reviewer is board certified in plastic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi 400 mg and Daklinza 60 mg for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks and Sovaldi with Daklinza for 12 weeks are both recommended as first-line regimens for non-cirrhotic treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%), and ALLY-3 for Sovaldi with Daklinza, which showed a 97% cure rate in non-cirrhotic patients. In this case, due to the patients lack of fibrosis stage 2 or higher, criteria for Epclusa is not met per the Health Plan policy. As such, Sovaldi and Daklinza is medically necessary and the only available treatment recommended by the guidelines. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld

A 75-year-old female enrollee has requested for octreotide for treatment of her nausea. Findings:  Three physician reviewers found that octreotide has been used in the treatment of nausea and vomiting following chemotherapy. However, there is no data in the peer-reviewed journals on the safety and efficacy of octreotide in the management of nausea in patients with either gastroparesis, GERD or CREST syndrome. As such, there is insufficient evidence supporting the use of octreotide for patients such as this patient. There are other medications/modalities available for the management of her symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested a coronary calcium scan for evaluation of the enrollees history of chest pain.  Findings:  Two physician reviewers found that per the current medical evidence, the requested services are likely to be of greater benefit than other methods of evaluating this patient.  This patient has an intermediate risk profile for coronary artery disease.  She has a history of chest pain.  However, initial non-invasive testing did not confirm flow-limiting coronary artery disease.  Current guidelines support coronary artery calcium scanning for intermediate risk patients.  There is an additional benefit for coronary calcium scoring for persistently symptomatic patients.  The results of the coronary calcium scan can be used to guide treatment planning.  A coronary calcium scan is a non-invasive and appropriate method to further investigate this patients persistent chest symptoms and assess long-term risk.  Thus, the requested services are likely to be more efficacious than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old female with a history of chronic plantar fasciitis. Conservative therapy consisted of non-steroidal anti-inflammatory drugs, icing and stretching, steroid injections and orthotics. Additionally, the patient underwent plantar fasciotomy surgery in June of 2005. None of these interventions have successfully relieved her right foot pain. The patient is now requesting authorization for extracorporeal shock wave therapy (ESWT).  The Health Plan had denied her request citing a lack of medical necessity.A review of literature related to ESWT reveals that optimal treatment parameters have not been established, patient selection criteria has not been adequately defined and there is limited information regarding the durability of the treatment effect or the long-term adverse effects. A recent randomized, placebo-controlled, double-blinded, clinical trial yielded results that contradict previous positive findings; raising further doubts as to the efficacy of the therapy. There is no data available that would suggest that ESWT would be effective after fasciotomy, and it is unlikely that this patient would benefit from the therapy.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested for continued skilled nursing facility (SNF) care for treatment of his end stage liver disease.  Findings:  The physician reviewer found that the patient does not require daily skilled nursing services for administration of parenteral medications, monitoring, or maintaining skin care (no stage 3 or worse skin condition was documented).  Further, the patient does not require skilled nursing care for routine care of rectal tube or condom catheter.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cardiology consultation and/or vascular/extremity study. The records provided for review document that this patient presents with possible post-thrombotic syndrome (PTS). A combination of reflux due to valvular incompetence and venous hypertension due to thrombotic obstruction is thought to underlie the pathophysiology of PTS. Symptoms and signs of PTS may include leg pain, leg heaviness, vein dilation, edema, skin pigmentation, and venous ulcers. The patient has requested a cardiology consultation with a provider who also performs vascular consultations given his dissatisfaction with the outcome of his vein ablation. Kahn and colleagues noted that, A number of clinical tools or scales have been used to help diagnose and define PTS. Of these, three were developed specifically to diagnose PTS after objectively diagnosed DVT: the Villalta scale, Ginsberg measure, and Brandjes scale. In this clinical setting, evaluation and treatment with a vascular surgeon, rather than a cardiologist, is appropriate. Based on the available documentation, additional imaging with a vascular/extremity study is not indicated. All told, the requested cardiology consultation and vascular/extremity study are not medically necessary for this patient.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 internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 50-year-old male has requested Oxycontin 40mg tablet (#60), twice per day for treatment of his cervical disc disease.   Findings:  The physician reviewer found that based on review of the available records, the requested Oxycontin is not medically necessary for treatment of this patients medical condition. Such narcotics and at the doses prescribed to the patient is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic neck and wrist pain which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain (Fishman). Baron and colleagues reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in this patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. In addition, Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary level care for intraocular lens exchange. Davis and Pineda note that the most frequent indication for intraocular lens exchange surgery was dislocated intraocular lenses, and that the second most frequent indication was patient dissatisfaction after multifocal intraocular lens implantation. Kim and colleagues note that multifocal intraocular lens exchange can be performed safely with good visual outcomes using different types of intraocular lenses. In this case, the patient has blurry vision, possibly attributed to intraocular lenses. Given that this patients condition could be treated surgically by an ophthalmologist, and that the documentation does not reflect emergent conditions or that special services are required, the requested service is not medically indicated. Therefore, tertiary level care for intraocular lens exchange is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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: An enrollee has requested Harvoni for 24 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that Harvoni for 24 weeks is not medically necessary for treatment of the patients medical condition. In this case, the patients presents with a diagnosis of HCV genotype 1a with a high viral load without advanced fibrosis. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). However, guidelines recommend daily Harvoni for 12 weeks for patients with HCV genotype 1 infection. Thus, a 24-week course of Harvoni is not AASLD/IDSA recommended in this patients clinical setting. For the reasons provided, the request for Harvoni for 24 weeks is not medically necessary for treatment of 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 partially upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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

The patient is a 68-year-old female who is in need of a screening colonoscopy. Because of her previous bad experience during a flexible sigmoidoscopy, she is requesting authorization for MAC anesthesia during the colonoscopy.  The Health Plan denied her request based upon a determination that the requested services are not medically necessary.There is no objective medical indication for MAC anesthesia documented in the record provided for review. It does not appear that the patient has ever had a colonoscopy or had a bad experience with a colonoscopy where conscious sedation was used. The use of anesthesia during a colonoscopy is not the standard of care.  Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A 48-year-old male enrollee requested emergency medical services for medical care of his right middle finger.  Findings:  The physician reviewer found that California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical documentation demonstrates that the services provided did not meet prudent layperson for emergency care. While the patient had an urgent need for surgical intervention, he was not experiencing an emergency medical condition as defined above.  Based on the initial evaluation by the treating surgeon, there was no documentation of delayed capillary refill, duskiness, and/or pale color. This was only documented the next day on indications for surgery.  In addition, if the patient had a devascularized finger, i.e., threatened finger, then standard of care would dictate emergent treatment on the same day, which did not occur in this case. The patient is noted to have been seen three days after the accident and another day elapsed before definitive treatment was carried out. Thus, this would not be considered immediate medical treatment as contemplated by the above definition of emergency medical condition. Based on all these factors and the medical records reviewed, although the patient required urgent treatment, he did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested Potaba 500mg for the treatment of his Peyronies disease. Findings:  The physician reviewer found that treatment of Peyronies disease can be challenging. Oftentimes treatment consists of both surgical and medical treatment, with medical treatment being a good initial approach. Potaba, among other drugs, has been used with variable results. The recommended dose is as indicated by the patients treating physician. Since medical treatment of Peyronies disease is a good initial approach as indicated in the article by Trost and colleagues, Potaba is medically indicated for this patient for treatment of his medical condition.