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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX testing for evaluation of the enrollees newly diagnosed breast cancer. Findings:  2/3 of the physician reviewers found that the patient has invasive ductal carcinoma, invasive breast cancer, in addition to surrounding DCIS ductal carcinoma in situ (DCIS). Early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in postmenopausal women. In this case, there is a 15% chance of recurrence. It is this 15% that needs adjuvant chemotherapy. More recently, the Oncotype DX has been included in the guidelines of the American Society of Clinical Oncology (ASCO) for biomarker analysis. The analysis of the ASCO panel states that Although performed retrospectively, the validation of this assay using a prospectively collected clinical trial data set, but retrospectively collected tissues from the data set, might be considered as Level of Evidence I for use of this assay. In addition, there is sufficient support in the peer-reviewed literature for Oncotype DX in post-menopausal patients. In this case, its use was clinically indicated and appropriate. Therefore, the Oncotype DX testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the testing at issue was 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 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: Urgent Care
Decision: Upheld

A 25-year-old female enrollee has requested ambulance transfer services for treatment of her complaints of shortness of breath and chest pain.  Findings:  The physician reviewer found that in order for ambulance transport to be medically indicated, the patient must require services that only a fully equipped ambulance can provide. A patient is considered to be bedridden if she cannot remain seated in a wheelchair without assistance. A second issue, regardless of bed confinement, is whether the patient required medical services from the paramedics. This patients records indicate that she was not short of breath or unstable. She did not require oxygen, intravenous medications, or any medical intervention during her transport. She did not require the services that only a fully equipped ambulance can provide. The patient states that she called for an ambulance because, due to her history of seizures, she is not allowed to drive. However, ambulance transport is not covered for purposes of convenience or if other modes of transportation are unavailable. Thus, a prudent layperson would not have reasonably believed that transportation via ambulance was necessary when standard transportation would have been adequate in this patients case. All told, this patient could safely have been transported by means other than ambulance.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee requested authorization and coverage of a custom wheelchair and pressure relief cushion. The Health Plan denied the request indicating that the requested equipment is not medically necessary for the enrollees mobility.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested  for acupuncture therapy for treatment of  her elbow and knee pain. Findings:  The physician reviewer found that acupuncture is a modality for the management of chronic pain. It is generally utilized to control or modulate chronic symptoms recalcitrant to more conservative or traditional evidence-based treatment approaches.A cortisone injection might also be considered. There is no evidence to suggest a chronic pain condition requiring acupuncture.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cimzia 200 mg syringe every other week for four months. Researchers reported that TNF inhibitors are well-established, effective drugs in the treatment of ankylosing spondylitis symptoms. The provider reported that the patient has failed treatment with Humira. However, the patients records do not document treatment failure or contraindication to anti-tumor necrosis factor (TNF) agents including Enbrel and Cosentyx, which are first-line therapies for the treatment of HLAB27 positive ankylosing spondylitis. In addition, the documentation does not report that the patients condition has failed to improve with maximally dosed non-steroidal anti-inflammatory drugs (NSAIDs). All told, Cimzia 200 mg syringe every other week for four months is not medically necessary for treatment of this patient. 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 rheumatology 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 58-year-old female enrollee has requested radiofrequency ablation of the lumbosacral joint x 2 (CPT 64635) and the lumbar spine x 4 (CPT 64636) for treatment of her axial pain in the lower back.  Findings:  Two physician reviewers found that the requested radiofrequency ablation of the lumbosacral joint and lumbar spine is supported as likely to be more beneficial than standard therapies on the patients left side. The records do not provide an indication for this procedure on the right side as no diagnostic injections have been performed to confirm the right sacroiliac joint as a possible pain generator. In addition, the requested L4-5 and L5-S1 facet joint/medial branch bilateral radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The records indicate that this was helpful for almost a year for the patient previously. For these reasons, bilateral radiofrequency ablation of the lumbosacral joint (CPT 64635) and left side lumbar spine (CPT 64636) are likely to provide this patient with an improved health outcome when compared with standard therapies. Therefore, a portion of the requested services should be approved.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-month-old male enrollee has requested for Similac Alimentum Formula for treatment of his milk/soy protein allergy. Findings:  The physician reviewer found that adverse reaction to cows milk protein is quite common in infants, with between 5% and 15% showing symptoms. The prevalence of cows milk protein allergy (CMPA) ranges from 2% to 7.5%. Symptoms of mild to moderate CMPA include urticaria, angioedema, regurgitation, vomiting and/or diarrhea, constipation, blood in the stool, persistent colic, atopic dermatitis, and respiratory problems. Severely allergic infants may present with failure to thrive, feeding refusal, protein-losing enteropathy, and large amounts of blood in the stool. A comprehensive history is crucial in making the diagnosis of CMPA, including family history, because the risk is increased in the presence of familial atopic diseases.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-seven year-old male who is status post an intracranial hemorrhage is requesting continued skilled nursing facility services.  He has received two procedures and was transferred to a skilled nursing facility. Reviewers Findings:The reviewing physician found that the continued rehabilitation services are not medically appropriate at this time.  However, the patient should be reevaluated in 30 days as there may be improvement with a hemorrhagic stroke.  Therefore, the reviewing physician concluded that the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage of a PET scan and prostate saturation biopsy that were performed.  Findings: Two physician reviewers found that in the current peer-reviewed medical literature, an author reported that positron emission tomography (PET) is a valuable imaging modality in prostate cancer. The authors noted that the main role for PET imaging is for restaging of patients with biochemical recurrence after radical prostatectomy or external beam radiotherapy. Gleason score and prostate-specific antigen value, doubling time, and velocity can influence positivity of PET. However, conventional imaging that includes bone scan and computed tomography (CT) scan remain the gold standard for evaluation in this clinical setting. Therefore, a repeat biopsy within a year and PET scan were not indicated.Final Result: The reviewers determined that the requested services 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 urology 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

A 25-year-old female enrollee requested intensive outpatient program (IOP) services for medical treatment of the enrollees polysubstance dependence, anxiety, depression, and post-traumatic stress disorder (PTSD).  Findings:  The physician reviewer found that episodic placement in more restrictive settings is often clinically appropriate for patients with serious mental and addictive illness. Applying the American Psychiatric Association (APA) guidelines, the records support the medical necessity of IOP services while the patient was actively involved in her treatment; while the providers were mobilizing the patient towards community programming to facilitate a smooth transition to a less restrictive setting; when she met with a psychiatrist resulting in a dose increase of her antidepressant and the addition of an anxiolytic medicine,  and while she was focusing on longstanding issues with her mother which was relevant to the transition plan as the patient resided at home.  Overall, the records indicate that a portion of the substance abuse treatment services provided at the IOP level of care were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for a group three power wheelchair with power tilt and power center mount. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees back pain and degenerative joint disease.At issue in this case is whether the requested group three power wheelchair with power tilt and power center mount is medically necessary for treatment of the patients medical condition.The records indicate that the patient has multiple chronic medical conditions but her primary mobility-related issue is bilateral knee arthritis. She has demonstrated normal upper limb strength on examinations by multiple different providers. Per the most recent physical therapy evaluations, the patient is independent with weight shifts and requiring minimal assistance for transfers and getting to the stand position, the latter of which was assessed while she was still an inpatient in the hospital in 9/18. The patient, moreover, has health conditions that would be better addressed through higher levels of physical activity, rather than the lower levels of physical activity that a power mobility device with power tilt and power leg elevation would encourage. Power tilt and power center mount leg elevation are not medically necessary for this patient. The group three power wheelchair base has been requested to accommodate the power tilt and power center mount leg elevation functionality. Therefore, the requested underlying group three power wheelchair base is also not medically necessary. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation 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 reimbursement for insertion of presbyopia correcting intraocular lenses (V2788) after cataract surgery and the use of a laser (ZCAT) to assist with performing the cataract surgery. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Findings: Femtolaser assisted cataract surgery (FLACS) and presbyopia correcting intraocular lenses are not considered a medical necessity in standard cataract surgery. Femtolaser has been utilized in different aspects of cataract surgery such as creation of incisions, arucate keratotomies, and anterior capsulorrhexis and nuclear fragmentation.  Studies have indicated that FLACS does not carry additional risk compared to non-FLACS small incision phacoemulsification cataract surgery. Currently, there is not sufficient evidence that FLACS offers better outcomes than non-FLACS small incision phacoemulsification cataract surgery for standard cases with a basic monofocal IOL.  Presbyopia correcting lenses are offered to patients as an out-of-pocket expense to provide less spectacle dependence for intermediate and near vision. Monofocal lenses provide excellent outcomes for single vision correction (distance or near) and are considered the standard of care. Therefore, the insertion of presbyopia correcting intraocular lenses after cataract surgery and the use of a laser to assist with performing the cataract surgery were not medically necessary for the treatment of this patient. 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 ophthalmology 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 49-year-old man with multiple medical problems. He has requested coverage for growth hormone (GH) for presumed adult GH deficiency (AGHD) based on nonspecific symptom, IGF-1 concentrations, and a sub-optimal response to an unknown GH stimulation test. The patient has type 2 diabetes, depression, obesity, abnormal liver function tests, hypothyroidism, hypogonadism, and is on a variety of medications, which could affect GH and GH stimulation tests. The Health Plan has denied coverage for GH therapy on the basis it is not medically necessary.The diagnosis of AGHD is generally based on the clinical context, signs and symptoms and the results of biochemical testing. The patients signs and symptoms are sufficiently nonspecific and GH stimulation tests sufficiently inaccurate that it is possible to have a false positive diagnosis unless the clinical context in which the testing is performed is compelling.The submitted records provide no evidence for AGHD in this patient. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic pituitary axis. Other causes for the patients symptoms could be his depression, poorly controlled diabetes, hypothyroidism or obesity. These must be considered before undertaking a course of testing for AGHD. With the exception of his hypogonadotrophic hypogonadism, the rest of the tested pituitary hormones appear normal. The patients MRI results show no structural lesion in the pituitary. His low GH levels and inadequate response to the GH stimulation tests in this context could be caused by any of his other conditions. As such, there is insufficient evidence that GH is medically indicated for this patient.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested a PET scan for an evaluation of his renal cell carcinoma. Findings:  Two physician reviewers found that the patient has repeat testing showing a GFR of 46 and a creatinine of 1.6 places him at risk for contrast-induced nephropathy and contrast infusion would be a study with considerable risk.  In this case, since there is only one remaining kidney, a combination unenhanced CT with PET, would be the procedure of choice to evaluate for tumor staging.  The rationale is this:  An unenhanced CT would be of little value in the detection of abdominal metastases, especially liver.  The combination of a PET scan with an unenhanced CT would be the best way to search for local metastases in order to properly stage.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage of laparoscopic placement of a gastric band for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the laparoscopic placement of a gastric band is not likely to be more beneficial for treatment of the enrollees obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested intensive outpatient program (IOP) treatment for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that the patients participation in IOP helped accomplish his successful return to school. Having been absent for almost half of the academic year, the patients return to school was a significant stressor, placing him at risk. By having the patient continue the IOP during his first week of school re-entry, he was afforded some stability, as well as a means to express his frustrations and to receive encouragement to continue to attend school. After his first successful week of school, further therapy could have been continued as an outpatient, by incorporating one group therapy session, one family therapy session and one individual therapy session each week.  The notes from the program beyond the date in question do not describe any major problems that could not be safely and appropriate addressed his outpatient psychiatrist and therapist. The patient appears to interact well with the group and to be compliant with therapy. As such, the patient was appropriate for step-down to a less intensive level of care after the said date.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of cranial nerve neurostimulator electrodes and generator. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Per the medical evidence, there are significant limitations regarding this new therapy. There is a lack of studies demonstrating the efficacy of the requested services on patients with a BMI greater than 32 kg/m2. Per the medical evidence, it cannot be concluded that the requested services would be effective in this clinical setting. Multiple important clinical questions remain about the use of this therapy. Therefore, the requested implantation of cranial nerve neurostimulator electrodes and generator is 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 neurology with sub-specialty certification in sleep 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.