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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who had a history of ductal carcinoma in situ.  Findings: Three physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue has been described as dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient. Final Result: Three reviewers determined that the service 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee has requested Aciphex 20mg for treatment of his acid reflux.  Findings:  The physician reviewer found that there is a lack of documented evidence of gastroesophageal reflux disease, either by history or objective testing. There is no documentation of an EGD, barium esophagram or esophageal pH study.  Even if gastroesophageal reflux disease were confirmed, the current medical literature demonstrates that PPI therapies are generally equivalent. In particular case, the Health Plan has offered formulary alternatives, including omeprazole, Prevacid and Nexium.  An adequate trial of these medications is medically appropriate prior to authorizing coverage for Aciphex.  The medical records do not demonstrate that the patient has had an adequate trial of these preferred PPIs. The submitted documentation does not demonstrate the medical necessity of the requested medication.  All told, Aciphex 20mg is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested coverage for a functional magnetic resonance imaging (fMRI) scan of the brain for evaluation of his arteriovenous malformation (AVM) of the brain.  Findings:  Two physician reviewers found that the patient was diagnosed with a left parietal arteriovenous malformation (AVM) in 2008 secondary to a syncopal episode.  He was neurologically intact at the time and an MRI/MRA demonstrated a superficially located AVM over the left parietal convexity with a three centimeter nidus.  He was treated with Gamma Knife radiosurgery but follow-up CTAs since that time have not shown any decrease in the size of the AVM.  The patient is now considering repeat Gamma Knife treatment or surgery and an fMRI has been requested to assist in deciding between the two.The available peer reviewed medical literature that is relevant to this patient consists of case reports and case series which demonstrate the feasibility of identifying what are presumably eloquent brain areas. There are no studies, however, that actually determine the sensitivity and specificity of fMRI in comparison to the gold standard of intra-operative mapping in identifying eloquent brain areas. There is also a case report in the literature which indicates that functional magnetic resonance imaging mapping in a patient with an AVM can be misleading (Juenger, et al.).  Given the lack of evidence demonstrating the efficacy of fMRI mapping in patients with AVMs, it should be considered an unproven technique at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Guardant 360 test for evaluation of the enrollees non-small cell lung cancer. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Patients with adenocarcinoma of the lung found to have certain epidermal growth factor receptor (EGFR) mutations are appropriately treated with erlotinib. Upon progression, it is important to reassess their mutation status, to see if the cells now have a T790M mutation, for which there is a specific and approved treatment, Tagrisso. This latter testing can be done by plasma testing via Guardant 360 test. In this patients case, Guardant 360 test was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: The reviewers determined that the services at issue were 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: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a cervical total disc replacement utilizing the Mobi-C artificial cervical disc for treatment of her disc degeneration with stenosis.  Findings:  Two physician reviewers found that the request for cervical total disc replacement utilizing the Mobi-C artificial cervical disc is not likely to be more effective for this patient than other available options. There is a lack of adequate studies in the peer-reviewed literature supporting multi-level disc replacement. A study by researchers reviewed the data concerning the role of cervical arthroplasty in reducing adjacent-level degeneration. The authors concluded, Adjacent-level degeneration has not been adequately studied in a review of the available randomized controlled trials on this topic, and there is no clinical evidence of reduction in adjacent-level degeneration with the use of cervical arthroplasty. Moreover, cervical disc replacement is indicated in single-level degenerative disc disease. In this case, the patient has multi-level degenerative disease. In addition, long-term, adverse effects of arthroplasty materials, such as metallic and polymeric debris, are not known at this time. For the reasons provided, the requested procedure is not likely to be more beneficial for the patient's medical condition than any other available standard therapy. Final Result: Two reviewers determined that the requested services are 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 reviewers are board certified in orthopedic surgery 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: Overturned

A 53-year-old male enrollee has requested for Synvisc injections for treatment of his osteoarthritis. Findings:  The physician reviewer found that this patient has attempted and failed several NSAIDs. In addition, he is unable to tolerate additional treatment with NSAIDs because of stomach irritation and bleeding issues. The patient has also failed cortisone injections and arthroscopic debridement.  He would like to put off knee replacement as long as possible because of his young age.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cabometyx tablet 60 mg and 40 mg for a total of 100 mg. Soft tissue sarcomas are a diverse group of cancers that comprise over 50 different histologic subtypes (Linch, et al.). Alveolar soft part sarcoma has a pathognomonic translocation that can lead to the production of pro-angiogenic factors, which provide the basis for anti-angiogenic therapy. This patient was treated with sunitinib with progression of disease. His provider has recommended treatment with Cabometyx, which is a multi-function tyrosine kinase inhibitor. The U.S. Food and Drug Administration (FDA) has approved Cabometyx for the treatment of progressive metastatic medullary thyroid cancer. Several small studies have shown activity of Cabometyx against soft tissue sarcomas (Schoffski, et al.; Chuk, et al.). Based on the available medical evidence and this patients progression while on sunitinib, treatment with Cabometyx is indicated. Based on the FDA approved dose for adults of 140 mg per day, and this patients documented weight of 99 kg, 100 mg daily is consistent with current guidelines. For these reasons, the requested Cabometyx tablet 60 mg and 40 mg for a total of 100 mg is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Cabometyx tablet 60 mg and 40 mg for a total of 100 mg is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Overturned

The parent of a two-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees stated condition of autism.  Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder (Dawson, et al.; Rogers, et al.; Warren, et al.; and Kelley, et al.). The scientific literature supports the use of ABA and guidelines recommend at least 25 hours per week for appropriate intervention (Rogers, et al. and Kelley, et al.). A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson, et al.). Warren, et al. reviewed 34 studies of early intervention in autism and 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. More recently, a retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcomes when compared to typically developing peers and peers with high-functioning ASD. The results indicated that 62% of children in the optimal outcome group received intensive behavioral therapy, including greater than 20 hours per week of intervention therapy, whereas only 13% of the high-functioning group received this level of intervention. Therefore, data suggests that treatment intensity may play a role in optimal outcomes (Kelley, et al.). In conclusion, the request for ABA therapy at a frequency of 25 hours per week is medically appropriate and necessary for treatment of the patients medical condition and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for bilateral foot inserts, removable, molded to patient model, longitudinal/metatarsal support orthotics (CPT L3020). Healy and Chen note that plantar fasciitis is a common cause of heel pain, and treatments vary from stretching exercises to different surgical options. Orthotic devices, including custom functional orthotics, are standard of care treatments for plantar fasciitis that keep the feet in a more neutral position, reducing over pronation and excessive strain on the plantar fascia and allowing for healing of the plantar fascia and reduction of plantar foot pain. In this case, the patient has bilateral hyperpronation of the feet and angles and pes valgo planus deformity, and a diagnosis of plantar fasciitis. Given that custom orthotics are standard of care for the treatment of plantar fasciitis, the requested equipment is medically indicated. Therefore, bilateral foot inserts, removable, molded to patient model, longitudinal/metatarsal support orthotics (CPT L3020) are medically necessary to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in podiatry 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 50-year-old female enrollee has requested reimbursement for laboratory testing (apolipoprotein A-1, apolipoprotein B, high sensitivity C-reactive protein, lipoprotein (a), and lipoprotein-associated phospholipase A2).  Findings:  Three physician reviewers found that the patient has a history of obesity, glucose intolerance on Glucophage, and hyperlipidemia.  She was evaluated for cardiac risk and was referred for specialized laboratory evaluation. The Health Plan has denied reimbursement for the tests in question.  This patients medical history is significant for glucose intolerance on Glucophage, hyperlipidemia, and obesity.  She is at increased risk for coronary artery disease compared to age and gender-matched controls.  The patient has had multiple standard fasting lipid profiles which show increasing hyperlipidemia.  A reasonable risk assessment and plan to possibly treat the known hyperlipidemia in the presence of the other cardiac risk factors could be made using standard lipid analysis.  The current data remain limited and conflicting with regard to lipoprotein fractional assessments.  The most recent guidelines do not recommend the use of apolipoprotein A-1, apolipoprotein B, and lipoprotein (a) in asymptomatic individuals.  However, there is adequate medical evidence supporting high sensitivity C-reactive protein and lipoprotein-associated phospholipase A2 in this clinical setting.  In sum, high sensitivity C-reactive protein and lipoprotein-associated phospholipase A2 were likely to have been of greater benefit than other modalities for evaluating this patient.  The submitted documentation fails to demonstrate the superior efficacy of apolipoprotein A-1, apolipoprotein B, and lipoprotein (a).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the prothrombin G20210A (Factor II) mutation testing and methylenetetrahydrofolate reductase (MTHFR) mutation testing for evaluation of the enrollees recurrent pregnancy losses. Findings:  The physician reviewer found that while meta-analyses and a retrospective cohort study have revealed an association between inherited thrombophilias and first-trimester pregnancy loss, prospective cohort studies have found no association between inherited thrombophilias and fetal loss. Therefore, the prothrombin G20210A (Factor II) testing was not indicated in this patient. Homozygosity for the MTHFR gene mutations is the most common cause of hyperhomocysteinemia, but MTHFR mutations alone do not appear to convey an increased risk for venous thromboembolism or pregnancy complications. Thus, the testing for MTHFR was also not medically indicated in this patient. Given these findings, the prothrombin G20210A (Factor II) mutation testing and MTHFR mutation testing performed were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All 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: Physician reviewer number one is board certified in obstetrics and gynecology 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 obstetrics and gynecology 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 obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Orthovisc injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that in this patients case, the submitted documentation does not demonstrate the medical necessity of the requested services.  There is a lack of support for the requested Orthovisc injections in this clinical setting.  Per the current medical evidence, there is a documented incidence of aseptic inflammatory reactions due to allergic response.  This patient has had multiple injections and with each injection there is an increased risk of allergic response.  There is also a risk of iatrogenic infection within the joint.  Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint in some cases requiring arthrocentesis after multiple injections.  Well-designed, double-blinded studies have documented limited or no benefit of viscosupplementation for the treatment of this patients condition.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old female who experienced approximately a 100-pound weight loss following gastric bypass surgery. The patient consulted a plastic surgeon regarding removal of excess hanging skin of the ptotic breasts, arms, and abdomen. The procedures requested were mastopexy, removal of excess skin from arms and trunk and a ventral hernia repair. Though a ventral hernia was previously documented by the patients physician no evidence of the hernia was found on a recent ultrasound of the abdomen. The Health Plan has denied authorization for the requested procedures citing lack of medical necessity.The submitted documentation, including photographs of the patient, does not establish medical necessity for the requested procedures. Evidence of a functional impairment has not been provided. There is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. Furthermore, with regard to the requested ventral hernia repair a recent ultrasound of the abdomen revealed no evidence of an abdominal or ventral hernia. Therefore, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old female enrollee has requested a continuous passive motion (CPM) machine use for treatment of the enrollees avulsion fracture. Findings:  The physician reviewer found that the studies note effects of CPM range of motion are too small to justify its use, and early implementation of range of motion rehabilitation results in a more rapid return to full activity. In a study by Harvey and colleagues, the authors noted the effects of CPM usage on knee range of motion are too small to justify its use. Overall, there is weak evidence that CPM reduces the subsequent need for manipulation under anesthesia. Patel and colleagues noted after definitive treatment, early implementation of range of motion rehabilitation results in a more rapid return to full activity. In the medical records reviewed, the provider did not indicate why CPM for improved range of motion was required as well as active physical therapy. Therefore, the CPM machine provided from the specified timeframe was not medically necessary for treatment of the patients medical condition.