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

A 62-year-old male enrollee requested an automatic implantable cardioverter defibrillator for medical treatment of his health condition.  Findings:  Two physician reviewers found that in this patients case, the device at issue was likely to have been more effective than other available modalities.  The current medical evidence supports the automatic implantable cardioverter defibrillator in this clinical setting.  The submitted records document severe obstructive hypertrophic cardiomyopathy on maximum medical therapy.  Additionally, the patient demonstrated a hypotensive response to exercise.  Given this patients multiple high-risk factors, the device at issue was medically appropriate.  In sum, the automatic implantable cardioverter defibrillator 3 was likely to have been of greater benefit than other options for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollees recto-sigmoid cancer. Findings:  Two physician reviewers found that the gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genetic testing of a tumor offers a comprehensive panel of molecular genetic markers on an individuals tumor to identify markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines it has not been determined that molecular markers are useful in treatment determination and prognosis other than KRAS, NRAS, and BRAF mutations. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 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: 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: Upheld

A 62-year-old male enrollee has requested a lumbar home traction unit for treatment of his low back pain. Findings:  The physician reviewer found that there is insufficient evidence from peer-reviewed published studies to conclude that spinal unloading devices such as lumbar traction devices are clinically effective in the management of chronic mechanical low back pain.  Fritz and colleagues noted that there may be a subgroup of patients that may benefit from mechanical lumbar traction.  This subgroup was reported to consist of patients with leg symptoms, signs of nerve root compression, and either peripheralization with extension movements or a crossed straight leg raise.  This study, however, was a small controlled trial with multiple limitations.  The literature that has been published in favor of use of the device includes case studies and other low-grade literature that does not establish clinical efficacy.  Overall, home lumbar traction has not been demonstrated to improve pain, health or functional outcomes for the condition of chronic mechanical low back pain.  All told, the requested lumbar home traction unit is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a sleep study for evaluation of her chronic insomnia. The physician reviewer found that the services at issue were not medically necessary for evaluation of the patients medical condition. According to the documentation submitted for review, the patient presented with sleep onset insomnia which is not an indication for a sleep study. Patients with clinically significant sleep apnea have decreased sleep latency. Also, there is a difference between fatigue and hypersomnia. The patient had a normal Epworth Sleepiness score and did not have hypersomnia. Hypersomnia is a cornerstone for a diagnosis of sleep apnea. In addition, the patients AHI was normal. She did not have sleep apnea and there was no indication for the sleep study performed. Based on the medical literature and documentation submitted for review, a sleep study was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee has requested coverage for CyberKnife radiosurgery for treatment of his anal squamous cell carcinoma. Findings:  Two physician reviewers found that the patient has essentially exhausted all conventional treatment modalities to control his tumor. He has experience with CyberKnife for his right pelvic mass and would like to attempt  treatment for this left pelvic recurrence. A surgical approach is not superior at this juncture. Surgery may not be successful in completely removing the pelvic tumor and might still require CyberKnife rescue. At this stage in treatment, a less invasive therapeutic modality offers clear advantage.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tocilizumab (Actemra) injections. Chronic antibody mediated rejection (ABMR) is the most common cause of graft failure and is more difficult to treat than acute AMBR, since tissue damage has occurred to the renal allograft. Chronic ABMR is also more common in patients who develop de novo donor specific antibodies (DSA) following kidney transplant. In terms of treatment, there is a lack of published randomized controlled clinical trials evaluating the efficacy of the various available therapeutic options for ABMR. Djamali and colleagues reported on a case series of patients treated with Actemra and noted that significant reductions in DSA and stabilization of renal allograft function were observed at two years. Given these preliminary data, additional clinical trials are needed to establish whether Actemra has a role in the treatment of ABMR. At this juncture, the current peer-reviewed medical literature does not support Actemra as likely to be more beneficial for treatment of this patients ABMR than standard available therapies. One reviewer found that Actemra is likely to be more beneficial for treatment of this patients ABMR than standard available therapies.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in nephrology 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: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee requested adalimumab (Humira) injections for medical treatment of the enrollees inflammatory spondyloarthritis and plantar fasciitis. Findings:  The physician reviewer found that the medical records document that the patient has failed multiple medications for the treatment of her inflammatory spondyloarthritis. Review of the medical literature shows that tumor necrosis factor (TNF) alpha inhibitors improve functional capacity and disease activity in both ankylosing spondylitis and non-radiographic axial spondyloarthritis (Callhoff, et al). Although many patients with spondyloarthritis respond well to non-steroidal anti-inflammatory drugs (NSAIDs), a small number of patients have resistant symptoms and are candidates for treatment with TNF inhibitors. The rapid clinical response to Humira in this patient shows the efficacy of TNF inhibition in the treatment of her disease. All told, Humira is medically necessary for treatment of this patients inflammatory spondyloarthritis.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old male enrollee requested authorization and coverage of appointments with a pediatric hematologist every six months. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees thrombophilia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that one additional visit to a pediatric hematologist is medically necessary prior to the enrollee transferring care to an adult hematologist.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for evaluation of the enrollees rectal cancer. Findings:  The physician reviewer found that the pathology report submitted for review showed an adenocarcinoma, however the report did not determine the depth of invasion. The tumor did appear within an adenomatous polyp suggesting that it likely did not penetrate the rectal wall. The specimen was submitted for mutational analysis through Foundation One. Typically, Foundation One testing is reserved for cases that have exhausted standard therapeutic options. There is a lack of documentation demonstrating that standard options are have been exhausted or were contraindicated for this patient. Adjuvant chemotherapy has significantly changed outcome for patients with all stages of disease. Modern regimens such as FOLFOX have even impacted the survival of stage IV patients compared to treatment with 5-FU/leucovorin. The standard of care chemotherapy regimen may include modification of the FOLFOX regimen, but targeted therapy that is genetically directed is premature at this clinical juncture. Accordingly, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for the evaluation of the enrollees risk of breast cancer.Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  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 37-year-old female enrollee has requested a power wheelchair (HCPCS code K0825) for treatment of her history of osteoarthritis of the knees. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The records forwarded for review do not establish that the patient would be confined to a bed or chair without a power mobility device.  The records indicate that she is requesting the power mobility device so that she can travel about her school campus.  Otherwise, she ambulates with a cane.  There is no documentation of physical examination findings, imaging findings or other objective findings that establish upper limb, cardiovascular or other pertinent organ system impairment that would preclude manual wheelchair propulsion for accomplishing mobility-related activities of daily living in the home.  This patient would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for individuals with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing performed.  Findings:  The physician reviewer found that : Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. The National Comprehensive Cancer Network guidelines endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling, such as Guardant360 testing, is considered standard of care.  In sum, Guardant360 testing performed  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 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers  are 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

A 28-year-old female enrollee has requested a consultation to determine her eligibility for a liver transplant under the requested center's criteria for treatment of her hepatocellular carcinoma. Findings: The physician reviewer found that this patient has shown no evidence of extrahepatic metastasis and is currently listed with a MELD HCC exception of 17.  At the location of the center she was listed, a MELD of 17 is not likely to improve her chances of receiving an organ, as currently the MELD score needed in that area is between 25 and 30, depending on blood type and size. This may be different at her requested (since patients are receiving livers at much lower MELD scores).  As per the patients transplant hepatologist, there continues to be no evidence of extrahepatic spread at over five years since her presentation.  The biology of her tumor appears to be very different from the usual cancer seen in the setting of cirrhosis or hepatitis B.  There is no evidence for any underlying disease.  As noted in the literature, selected liver transplant programs with selected patients have relatively positive results.  In this patients case, a consultation at the requrested center to determine her eligibility for a liver transplant under that centers criteria is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A transgender female enrollee requested bilateral orchiectomy for medical treatment of her gender identity disorder.  Findings:  The physician reviewer found that although not all patients with gender identity disorder wish to undergo surgical intervention, this patient has expressed a desire for surgery in treatment notes for a significant period of time. She has followed recommendations for surgery including living as a woman, participating in psychotherapy and undergoing hormone therapy. As such, there is sufficient evidence to support the medical necessity of the requested bilateral orchiectomy for treatment of the patients gender identity disorder.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested a power wheelchair for treatment of her quadriplegia. Findings:  The physician reviewer found that there is no indication in the records that the patients medical and functional needs support the medical necessity of a power mobility device. There are no documented impairments or postural issues that establish that her seating needs would be better addressed with a seating system on a power mobility device. Tilt-in-space and full recline functions can be provided on a manual wheelchair. Having attendant-controlled powered tilt-in-space and recline is for caregiver convenience but is not considered medically necessary. The patients ability to tolerate upright sitting would not be expected to be significantly improved with a power mobility device than a manual wheelchair. The patient would be expected to continue to be totally dependent for all mobility and self care with the requested power wheelchair. Specifically, she has significant cognitive and visual impairments that preclude independent use of a power mobility device. Given the duration of time that has passed since her original brain insult, no significant further recovery in cognitive or visual function would be reasonably expected (Brown, et al; van Velzen, et al). Consistent with these findings, the requested powered mobility device is not medically necessary for this patient based on the records available for review.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested  residential treatment services for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that this patient was referred to residential treatment with diagnoses of major depressive disorder, generalized anxiety disorder and parent-child conflict. She has a long psychiatric history that has included outpatient therapy, multiple medication trials and partial hospitalization services.  The treating physician indicated that the patient has been under his care from the said dates in question.  He noted that the patient has treatment-resistant depression and anxiety with repeat episodes of decompensation over the past 24 months.  Severe functional impairment was noted, and this included an inability to attend school.  The patient had difficulty with activities of daily living and was isolating. She also has a history of past suicide attempt and self-injury.  In this patients case, residential treatment services from the dates in question forward were and are medically indicated.  This patient has failed attempts at lower levels of care, she has serious functional impairment secondary to depression and anxiety, and there is an ongoing risk for self-harm.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested Oasis wound matrix (skin graft) for medical treatment of his medical condition.  Findings:  Three physician reviewers found that in this case, the wound had not failed other methods of management and thus was not a chronic, non-healing wound.  Furthermore, the application of the Oasis wound matrix to a wound measuring 0.3 cm in maximal dimension is an excessive use of the product.  All told, Oasis wound matrix (skin graft) was not likely to have been more effective than other treatment options.Final Result: Three 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: Reviewers 1, 2, and 3 are board certified in surgery 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

The parent of a 16-year-old male enrollee has requested a three-pack of inhalers for treatment of the enrollees asthma. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity in this patients case.  On the date indicated, the documentation noted that the patients asthma was well-controlled if he used Albuterol prior to exertion.  His respiratory examination was normal.  The patient was prescribed prednisone for asthma exacerbations.  The Health Plan has agreed to provide coverage for one inhaler at a time, and this is medically appropriate.  According to current guidelines, the use of albuterol more than a couple of times per week, except for exercise, is an indication of poor asthmatic control.  Per the submitted documentation, this patient has mild intermittent asthma from exercise.  Based upon the medical records, a three-pack of inhalers is not medically indicated for the treatment of this patient.