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

A 63-year-old female enrollee requested authorization and coverage for magnetic resonance imaging (MRI) of the breast. The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees stage IV non-small cell lung cancer.   Findings:  Three physician reviewers found that the patient has a history of stage IV adenocarcinoma of the left lung. She has a family history of breast cancer with an aunt and a grandmother succumbing due to this disease. There are no physical findings referable to a breast exam in the records and no mammogram or ultrasound reports describing equivocal findings. The oncologist requested an MRI of the breasts as a screening exam due to the patients family history. The Health Plan denied the request stating MRI of the breasts is not indicated without documented BRCA 1 or 2 genetic mutations and therefore the use of MRI in this instance is investigational. Although this patient has a diagnosis of stage IV lung cancer, the records provide little guidance as to the specific clinical indication for a breast MRI at this time. The patients oncologist does not outline reasoning for ordering this study as a screening tool in the absence of a first-degree or personal history of a BRCA genetic mutation. While this patient has a positive family history of breast cancer there are no first-degree relatives with the diagnosis to indicate a true genetic predisposition to the disease. Also, there is no equivocal imaging or clinical findings which provide an indication for MRI as a problem solving tool. As mammography is still the first-line of screening for breast cancer and the records do not provide any reason that technique should not be employed for this patient, the requested MRI has not been established as likely to provide novel and useful data relevant to this patients care at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for advanced lipoprotein testing. The provider believed the patients history of familial hypercholesterolemia, resulted in an increased cardiac risk for the patient. The advanced lipoprotein testing was ordered to monitor and treat her cardiac health. She had no clinical evidence of cardiovascular disease. The medical literature indicates LDL particle analysis testing, apolipoprotein B testing, and lipoprotein (a) testing does not represent the standard of care for cardiovascular risk reduction. The results do not predict or rule out the possibility of acute cardiovascular events, such as heart attacks and strokes. The results offer no proven clinical benefit over conventional lipid testing in the context of cardiovascular risk assessment. There is no established proven efficacy of these technologies, either in randomized clinical trials or meta-analyses, to support their benefit compared to conventional cardiovascular risk assessment methods, as their use has not been conclusively linked to improved cardiovascular outcomes. Despite these tests having approval, the enrollee does not stand to benefit from their use over conventional lipid testing and established risk assessment strategies The guidelines on the evaluation and treatment of hyperlipidemia put forth by a variety of different expert panels and organizations do not require advanced lipoprotein measurements. Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease and are 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: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested removal of bilateral saline-filled breast implants for the treatment of her condition. Findings:  The physician reviewer found that there is insufficient evidence that the proposed procedure is indicated based on general principles of medical necessity. The mammogram reports do not document abnormalities of the implants, leaking implants or capsular contractures or masses. There is no evidence that the etiology of the patients back pain and thoracic cage issues have been evaluated with diagnostic tools, medical evaluation, or been treated with physical therapy. Furthermore, there is a lack of documentation of Baker IV capsular contractures. As such, there is no medical justification for removal of the patients breast implants.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee requested KRAS gene testing for medical evaluation of the enrollees stage IV lung cancer with metastasis. Findings:  Three physician reviewers found that the presence of certain genetic abnormalities is clinically useful in picking the specific treatment of many cancers, including non-small cell lung cancer, particularly adenocarcinoma. Although the use of KRAS testing has been shown to be beneficial in patients with colorectal cancer, there is a paucity of data supporting its use in patients with non-small cell lung cancer. Thus, the KRAS gene testing was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested the Bioness L300 functional electronic stimulator for treatment of her foot drop secondary to multiple sclerosis. Findings:  Three physician reviewers found that recent literature suggests that the Bioness L300 is an effective device for the management of chronic foot-drop. The study by Hausdorff and colleagues found the Bioness L300 device improved both symmetry and speed of gait in 24 patients with chronic foot drop. Another study performed by the same group compared the effects of an ankle foot orthotic (AFO) versus a neuroprosthesis (such as the Bioness L300 device) on gait mechanics in 15 patients with chronic foot drop. Investigators observed better balance control during ambulation with use of the neuroprosthesis and concluded that the device was more effective than a standard AFO for the management of foot drop. From a clinical perspective, there has been increased use of the Bioness L300 for the management of chronic foot drop. The records provided for this review indicate the patient had an excellent clinical response to the Bioness L300.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee requested blepharoplasty (CPT code 15823) and repair of blepharoptosis (CPT code 67904) for treatment of his medical condition.  Findings:  The physician reviewer found that the documentation submitted for review indicated the patient had bilateral dermatochalasis.  It was recommended that the patient see an ophthalmologist to evaluate for visual field loss.  The documentation submitted for review did indicate the patient presented to an ophthalmologist , however, the documentation does not indicate or address the patients visual field.  As such, the degree of visual field loss cannot be established.  Given the lack of visual field testing and clear documentation of the peripheral vision being affected, the medical necessity for the proposed procedure is not established.  All told, the requested blepharoplasty (CPT code 15823) and repair of blepharoptosis (CPT code 67904) are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 60-year-old female enrollee has requested reimbursement for the Helicobacter Pylori antibody test for evaluation of the enrollees abdominal tenderness.  Findings:  The physician reviewer found that the limited information provided there is no compelling reason to check the patients Helicobacter Pylori status. In this clinical setting, if the pain persisted, the standard recommendation is to perform an upper endoscopy and biopsy for Helicobacter Pylori. If a non-endoscopic approach is chosen, the recommended ways to detect Helicobacter Pylori are with urea breath test and stool antigen. Therefore, the Helicobacter Pylori antibody test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Helicobacter Pylori antibody test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 60-year-old female enrollee requested BRCA gene testing for medical evaluation of her family history of cancer. Findings:  Three physician reviewers found that there is a lack of support for the requested BRCA gene testing.  At this time, genetic testing is not applied universally but rather to patients who exhibit family histories that are suggestive of inherited predispositions.  This patient has a significant family history suggestive of hereditary predisposition to cancer.  However, the types of cancer are more suggestive of mismatch repair gene defects as opposed to BRCA mutation.  Therefore, the requested services are not likely to be of greater benefit than other available options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested total ankle replacement with the STAR ankle system for treatment of his arthritis of the right ankle.  Findings:  Two physician reviewers found that there are now a significant number of peer-reviewed publications substantiating the use of a total ankle replacement in patients with end-stage ankle osteoarthritis, post-traumatic arthritis, and rheumatoid arthritis who have failed exhaustive conservative treatment.  The Scandinavian Total Ankle Replacement (STAR) prosthesis is a 3-piece mobile bearing, porous-coated, unconstrained device designed for uncemented implantation.  The stability of the prosthesis is provided by its anatomic shape as well as the patient's inherent ligamentous stability.  Evidence in the medical literature suggests that the results are optimal in those patients who are not obese, have no significant ligamentous instability, have minimal deformity, still have good range of motion, and have realistic activity expectations after replacement.  Absolute exclusion criteria for use of the STAR prosthesis, as outlined by Saltzman and colleagues, include patient weight greater than 250 pounds, insufficient ligament support, and a patient history of current or prior drug abuse or alcoholism. In this patients case, there are factors which constitute absolute exclusion criteria for total ankle replacement with the STAR prosthesis.  The first is obesity.  Although his weight is not greater than 250 pounds, his calculated BMI places him in the obese category. Additionally, the medical records on the said date document a history of alcoholism and prior addiction to narcotic medicine.  Besides these absolute exclusion criteria, the medical literature indicates that the results of total ankle replacement are optimal in patients who still have good range of motion, who have minimal deformity, and who have realistic activity expectations.  The providers examination documented that, in addition to his instability, the patient has a greater than 50% loss of motion with a fixed varus deformity of his ankle.  All told, this patient has numerous risk factors for an unsatisfactory outcome following total ankle replacement.  Ankle arthrodesis was likely to have been more beneficial for this patient.  Therefore, total ankle replacement with the STAR ankle system was not likely to have been more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for speech therapy twice per week for 60 minutes per session. The requested speech therapy at an intensity of 60 minutes twice a week is medically necessary for this patient. The patient has severe expressive language delay, and is unable to engage in interactive communication. Studies investigating the intensity of speech therapy and outcomes of treatment in children with autism spectrum disorder and delayed speech and language are limited. Researchers studied 1433 children and adolescents with autism spectrum disorder with respect to intensity of speech and behavioral therapy. The authors found that the majority of patients demonstrated improvement. Given this support, the requested speech therapy twice per week for 60 minutes per session is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology 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 an eight-year-old male enrollee has requested Humatrope growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that that the patient most likely has a constitutionally delayed adolescence with a height prediction approximating his mid-parental height.  For these reasons there is no clinical justification to treat this patient with growth hormone therapy. The patient does not meet accepted criteria for treatment with growth hormone therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the requested selective internal radiotherapy (SIRT) using Y-90 (CPT 37423) is medically necessary for treatment of the patients medical condition. This is a 64-year-old male who was diagnosed in 2015 with colon cancer and underwent surgery. He was staged as a T3N0M0. He did not receive adjuvant chemotherapy. In 2018 he was noted to have increasing abdominal pain. He was found to have an 8.3 cm mass in the right lobe of the liver. No disease was noted in the chest. His biopsy revealed a necrotic neoplasm. He was started on chemotherapy which he tolerated with no major complications. His repeat CT has shown no interval improvement in the size of the mass, and he is deemed inoperable.Findings:  The physician reviewer found that Patients with colon cancer that has spread to the liver are candidates for radioembolization (also known as SIRT) which has been shown to improve outcomes in this setting. The evidence suggests that radioembolization may be associated with a greater response which may facilitate eventual surgical resection (Shamimi-Noori et al and Fairchild et ano). National Comprehensive Cancer Network guidelines endorse the use of radioembolization therapy in this setting. The medical records indicate the patient has no contra-indication to receiving this therapy. Therefore, selective internal radiotherapy (SIRT) using Y-90 is medically necessary..Final Result: requested treatment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: I am board certified in radiation oncology and I am actively practicing. I am an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for home health care and skilled nursing visits for administration of IVIG infusions with Gammaplex 10%. Hovaguimian and Gibbons report that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain, and may involve the use of antidepressants, anticonvulsants, opioids, topical therapies, and nonpharmacologic treatments as part of the overall management of neuropathic pain. Finnerup and colleagues note that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. In reviewing the efficacy and safety of IVIG for apparently autoimmune small-fiber polyneuropathy, Liu and colleagues suggest that IVIG is safe and effective for rigorously selected patients with small-fiber polyneuropathy with apparent autoimmune causality.  In this case, the patient has a diagnosis small-fiber polyneuropathy and a history of autoimmune conditions. Her symptoms have persisted despite conventional medical therapy. Given current medical literature, the requested services are standard of care and medically indicated. Therefore, home health care and skilled nursing visits for administration of IVIG infusions with Gammaplex 10% are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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 43-year-old female enrollee who has a protuberant and enlarged abdomen. In addition, the patient indicates she experiences discomfort due to the excess skin. Her plastic surgeon has recommended removing approximately 5.5cm of fat centrally, which extend laterally to 3cm in thickness. The Health plan has denied this request indicating the requested procedure is cosmetic in nature and not a covered benefit.The patient is requesting abdominoplasty to address her large abdomen. There is no evidence of rashes on examination, and per her plastic surgery consultation, the abdominal fat is primarily intra-abdominal. The patients complaints include shortness of breath, back pain and diabetes. There is no historical basis that the abdominoplasty would help these problems, particularly in this patients case where the problematic fat is actually inaccessible by modern techniques. As such this patients complaints are cosmetic in nature. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested radiofrequency neurolysis procedure for treatment of her sacroiliac joint dysfunction.   Findings:  Two physician reviewers found that in the peer reviewed medical literature, Ferrante and colleagues reported on the results of radiofrequency denervations performed in 33 patients with SI joint syndrome. The results of the study suggested that radiofrequency denervation of the SI joint can significantly reduce pain in selected patients with SI syndrome for a protracted period. In addition, Yin and colleagues performed a retrospective audit to determine the effectiveness of sensory stimulation-guided radiofrequency neurotomy for the treatment of recalcitrant SI joint pain. The researchers concluded that a sensory stimulation-guided approach toward the identification and subsequent radiofrequency thermocoagulation of symptomatic sacral lateral branch nerves appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic SI joint complex pain. Moreover, Cohen and Abdi conducted a study to determine the efficacy of reducing SI joint pain by percutaneous radiofrequency lesioning of the nerves innervating the SI joint. The authors concluded that in patients with SI joint pain who respond to L4-5 dorsal rami and S1-3 lateral branch blocks, radiofrequency denervation of these nerves appears to be an effective treatment. For these reasons, the requested radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 9-year-old male enrollee has requested 8 hours per week of applied behavioral analysis (ABA) therapy and 3.5 hours of supervision per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills and adaptive behavior skills (Warren et al). Additional studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey and Hastings). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh et al). The goals for older children often are to identify and remediate particular deficits.Furthermore, Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. This patient has a diagnosis of autism through multiple sources and continues to present with concerns that are best addressed with ABA therapy. The records document behavioral concerns including noncompliance, screaming, aggression and maladaptive attention-seeking behaviors. Thus, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, ABA therapy is medically necessary for this patient.