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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decipher test.Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. Therefore, Decipher 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: 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

A fifty-two year-old female who is status post a right shoulder arthroscopy for adhesive capsulitis is requesting coverage for a continuous passive motion (CPM) device.Reviewers Findings:The reviewing physician found that the use of CPM in this case was clinically appropriate and within the standard of care. The patient has a condition that causes limited shoulder motion.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

 Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested A1C, B12, Iron, ferritin, and vitamin D testing for evaluation of the enrollees medical condition.   Findings:  The physician reviewer found that in this clinical setting, the submitted records support the medical necessity of the requested tests.  The American Diabetes Association (ADA) has established screening criteria for testing for type 2 diabetes or pre-diabetes in asymptomatic children. However, the ADA does not provide specific criteria for screening for other types of diabetes in youth. Based on the information provided, the patient would not strictly meet ADA criteria for screening for type 2 diabetes. But, as the nature of the parents pre-diabetes is unknown, it is possible that this patients parent may have a form of MODY (monogenic diabetes) which can be inherited in an autosomal dominant fashion. Therefore, it is reasonable to obtain a screening A1C test for the patient. As to the screening for other nutritional deficiencies, the patient is noted to have poor intake of fruits, vegetables, and dairy products. Vitamin D deficiency is common in adolescents, even in sunny areas.  It is reasonable to screen the patient for this deficiency during the adolescent period of maximal bone accretion to prevent long-term sequelae of vitamin D deficiency on bone mineral density. Iron deficiency in a menstruating adolescent female who does not consume adequate iron in her diet is also common, and screening is justified based on this patients dietary history. Furthermore, folate and B12 deficiency, although much less common, may be of concern if there is inadequate intake of these nutrients in the diet or any concerns about malabsorption. For all these reasons, the requested tests are medically indicated for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested tests are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for occipital nerve block injections provided and forward. Findings: The physician reviewer found that a diagnostic greater occipital nerve block may have a role in differentiating between cervicogenic headaches, migraine headaches, and tension-headaches. In this case, the patient has a diagnosis of headache which is poorly described in terms of location, character, frequency, or duration. The initial greater occipital nerve block procedure performed  was clinically indicated. However, therapeutic greater occipital nerve blocks are under study in the medical literature for treatment of occipital neuralgia and cervicogenic headaches. There is a lack of evidence in the peer-reviewed literature that therapeutic greater occipital nerve blocks provide sustained relief and current reports of success are limited to small, non-controlled case series. As such, the occipital nerve block injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, however not thereafter. Final Result: Two of the three  reviewers determined that portion of the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. Physician reviewer number two & three are board certified in anesthesiology with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica for treatment of the enrollee, who has been diagnosed with fibromyalgia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Regarding the stepwise approach to treatment of chronic pain associated with fibromyalgia, initiating therapy with a tricyclic is often the first step.  In patients with an inadequate response or with intolerance of a tricyclic, a serotonin-norepinephrine reuptake inhibitor or one of the anticonvulsants are recommended.  Monotherapy is recommended initially, and alternative drugs are added as the patient experiences symptoms.  In this patients case, the documentation does not support that the patient has failed treatment with gabapentin.  There is no objective documentation to support that the patient continues to have uncontrolled symptoms despite treatment with gabapentin.  All told, the requested Lyrica is not medically indicated for the 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 internal 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for out of network fertility services on the basis that she was experiencing an emergency medical condition. Unfortunately, there are few interventions proven to improve early pregnancy loss or recurrent pregnancy loss. While intralipid therapy infusions may be a promising therapy, it is not considered an emergency service. The infusion of intralipid was not a treatment for an emergency condition. There is no evidence the patient presented with acute signs and symptoms of an emergency medical condition or received services necessary to relieve or eliminate an emergency medical condition. Based upon the available evidence, intralipid therapy infusion is an unproven treatment for possible prevention of pregnancy loss. In sum, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the iStent surgery (CPT 0191T) for treatment of the enrollees glaucoma.    Findings:  Two physician reviewers found that the records provided for review document that this patient has mixed glaucoma which is described as stable. The patients intraocular pressures are in the normal range and the cupping of the optic nerves is not severe. However, the records do not include the patients visual fields or long-term trends in the progression of glaucoma. In addition, the documentation lacks specificity regarding prior medications used to treat the patients medical condition. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: All three physician reviewers are board certified in ophthalmology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast implant removal surgery. Based on the records provided for review, this patient has postural orthostatic tachycardia syndrome (POTS), saline breast implants, and symptomatic breast hypertrophy. Causation of systemic illness, including POTS, has not been associated with saline breast implants. Based on the American Society of Plastic Surgeons (ASPS) criteria, the patient does not meet the requirement for reduction mammaplasty. Specifically, there is no report of chronic breast pain due to the weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, or congenital breast deformity. There is no documentation of shoulder grooving. All told, the requested breast implant removal surgery is not medically necessary for treatment of 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 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: Upheld

A 54-year-old female has requested proton beam therapy for treatment of her pulmonary and spinal metastases secondary to progressive uterine leiomyosarcoma.  Findings:  The physician reviewer found that a proton is the charged nucleus of a hydrogen atom (hydrogen atom minus an electron).  Charged particles (such as protons and carbon) can be used to deliver therapeutic radiation. Standard radiation is delivered with a linear accelerators (LINAC), which deliver photon therapy (akin to high energy light), whereas protons (and other charged particles) are generated from a cyclotron. The difference between proton and photon irradiation is that the protons (or charged particles) stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue.Certain conditions, such as base of skull and spine chordomas and chondrosarcomas, and pediatric central nervous system malignancies are well-suited to treatment with proton therapy due to the sharp dose fall off, allowing high dose delivery to the tumor, while sparing the neighboring normal tissue. For this patient, there is no compelling reason to treat her spinal metastases with proton therapy versus conventional therapy. The submitted evidence indicates this patient has already started a course of external beam radiation for her spine metastases. She is receiving appropriate, standard treatment for her spinal lesions. The use of proton therapy in this setting is not standard of care and there is an absence of literature supporting its use in patients with metastatic disease to the spine.  Likewise, there are no published reports on the use of proton therapy for lung metastases.  For patients with lung metastases who are undergoing treatment with radiation, stereotactic-body radiotherapy (SBRT) has become standard therapy. While SBRT can deliver photon or proton irridation, there is a paucity of literature studying the difference in the two approaches. A study by Georg and colleagues found minimal dosimetric differences between photon and proton SBRT. Furthermore, the only studies published to date involve primary lung cancer rather than metastatic lung disease, which is involved in this case.All told, review of the relevant scientific literature as well as the clinical documentation submitted with this appeal does not establish the medical necessity of proton therapy for treatment of this patients spinal and pulmonary metastases.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy twice a week, or in the alternative physical therapy once per week. The records provided for review document that this patient has undergone extensive physical therapy for her knee condition. Physical examination notes reveal a lower extremity functional scale score of 50/80, which improved from 58/60 on prior testing. Improvement was noted in knee extension from 4-/5 to 3+/5 on the left, with the remainder of range of motion and gross muscle tests of the lower extremity unchanged since prior assessment. The patient has participated in extensive physical therapy, she has received thorough instruction on her condition, and she has been compliant in a home exercise program. The records do not demonstrate that the skills of a physical therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain the patients current condition or to prevent or slow further deterioration. All told, the requested physical therapy twice a week or in the alternative physical therapy once per week, is not medically necessary for treatment of 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facet block injections. The records provided for review document that this patient has chronic low back pain status post four lumbar surgeries including hemilaminectomy. He currently reports low back pain with radiation into the left leg. Physical examination demonstrated a positive straight leg test bilaterally as well as positive sacroiliac joint provocation maneuvers. The patients MRI from 2019 showed severe degenerative disc and joint disease affecting multiple lumbar levels there is also evidence of previous lumbar laminectomy, severe impingement of the left S1 nerve root, and moderate to severe foraminal stenosis at the L3-4 and L4-5 levels. His provider has recommended lumbar facet joint injections. The patient has documented signs and symptoms of lumbar radiculopathy into the left leg, which is supported by MRI evidence of left S1 impingement. The patients physical examination findings do not support a diagnosis of axial back pain, for which facet joint injections may be effective. Cohen and colleagues found that facet blocks have not been shown to be effective for therapeutic purposes. The authors concluded that, The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. A review by Manchikanti and colleagues stated that the best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure, in patients who do not have concurrent signs or symptoms of radicular low back pain. Overall, the medical literature or guidelines do not support facet block injections for the treatment of patients with lumbar radiculopathy. Therefore, the requested facet block injections 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the FoundationOne cancer assay providedFindings:  The physician reviewer found that  per a study, PARP inhibition has antitumor activity in cases of metastatic castrate resistant prostate cancer and that these responses are associated with DNA repair defects in tumor cells that can be identified through next generation sequencing assays. FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (Michels, et al). Given this support, the BRCA2, ATM, BRCA1, PALB2, CHEK2, FANCA and HDAC2 portions of the FoundationOne testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the FoundationOne cancer assay was not 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 a portion of 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 partially overturned. Credentials/Qualifications: Physician reviewers 1,2 & 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for a series of Orthovisc injections. The submitted documentation supports that the requested services are medically necessary. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Another study performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Orthovisc injections are medically necessary to treat the patients medical condition at this time.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 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.