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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDX melanoma gene assay performed. Findings:  The physician reviewers found that The patient has melanoma. Two lesions in the posterior neck area were excised. Pathology showed these were malignant melanoma arising out of a nevus with 0.2 mm depth of invasion. A sample of the tissue was submitted for the DecisionDX melanoma gene assay. The patient has requested reimbursement for the DecisionDX melanoma gene assay performed. The Health Plan denied reimbursement for the services at issue as investigational/experimental for the evaluation of this patients medical condition. The data on the DecisionDX test for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. The two prospective studies have been discussed within the National Comprehensive Cancer Network (NCCN) and it has been concluded that the patients analyzed were a high risk cohort. There has also been some lack of consistency between various genes being used as biomarkers. As such, this test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the NCCN guidelines. All told, DecisionDX melanoma gene assay performed was not likely to have been of more effective than the available standard therapy for the evaluation of this patients medical condition.Final Result: The reviewers determined that the services at issue were 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 upheldCredentials/Qualifications: Physician reviewers 1,2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. Each 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 autonomic testing.Findings:  Two physician reviewers found that a study notes autonomic testing may be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP).  In this patients case, the available medical records provided for review do not indicate any focal neurologic disturbance in regards to motor, sensory, reflex, coordination, gait or cranial nerve or cognitive function.  The available medical records do not report, by history, the presence of any issue of labile blood pressure, orthostatic hypotension, or passing out episodes. There is no indication of neuropathic pain being reported in terms of having hypersensitivity allodynia.  Autonomic nervous system testing is useful for evaluation of autonomic nervous system when there are autonomic nervous system related symptoms. The available medical records provided for review does not support the presence of any subjective symptoms consistent with autonomic nervous system abnormality or indicate any objective findings on physical examination and support of autonomic nervous system dysfunction.  Final Result: Two reviewers determined that the services at issue are 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: All three physician reviewers are board certified in neurology 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 four-year-old male with a history of expressive and receptive speech delay is requesting reimbursement and on-going authorization for speech therapy.Reviewers Findings:  The reviewing physician found that the clinical records do not indicate the patient will achieve a specific diagnosis-related goal or achieve measurable improvement within a reasonable and predictive amount of time.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for all and/or any of (immunoassay for interleukin-13; interleukin-10; interleukin-4; and interleukin-5). Researchers note that the general approach to diagnosis of food allergy include modalities such as a detailed medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin E (IgE) measurements, and oral food challenges. Current medical literature does not support the use of blood tests evaluating the levels of interleukins as part of the evaluation or treatment of food allergies, and do not document a proven benefit from such tests. Rather, the treatment of food allergies is either through strict avoidance of the food or oral immunotherapy under the care of an allergist. Therefore,  (immunoassay for interleukin-13; interleukin-10; interleukin-4; and interleukin-5) was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the CPT 83520 (immunoassay for interleukin-13; interleukin-10; interleukin-4; and interleukin-5) provided by Foundation Labs was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 is board certified in in internal medicine and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is certified in in allergy and immunology and in pediatrics 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an electric mobility chair for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The available records do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that the patients strength has been intact to mildly impaired and not unaddressable by strength training and exercise.  She does not have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living.  Physical activity, moreover, is generally appropriate and recommended for conditions such as diabetes, morbid obesity, osteoarthritis, chronic widespread pain, and for general musculoskeletal health.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments.  All told, the requested electric mobility chair is not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne Gene Panel testing for evaluation of the enrollees B-cell lymphoma. Findings:  2/3 of the physician reviewers found that there is sufficient support for the services at issue in this clinical setting. B-cell lymphomas are a heterogeneous group, and the diagnosis can be difficult to obtain due to limited tissue samples. Molecular genetic testing of the tumor can often help identify the type of tumor and avoid a more invasive procedure as well as sometimes aid in the guidance of treatment decision-making. In this patients case, the services at issue helped identify the type of low grade B-cell lymphoma this patient had while avoiding a surgical procedure. Therefore, FoundationOne Gene Panel testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2/3 of 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for eight weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Norco for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  In this patients case, non-opioid treatment options have not been exhausted. Her currently prescribed non-opioid medications have not all been optimized.  The timeframe for acute pain from the medical condition has ended.  If there is still pain, it would be chronic pain.  The current medical evidence does not support the use of Norco in this clinical setting.  All told, the requested medication Norco 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 anesthesiology with sub-specialty certification in pain 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: Overturned

A 57-year-old male enrollee has requested a mobility scooter for treatment of his degenerative joint disease and osteoarthritis. Findings:  The physician reviewer found that this patient has significant mobility impairments that cannot be successfully resolved by crutches, walker, or a manual wheelchair.  He is unable to use these devices on a consistent basis due to inflammatory changes in his hands due to rheumatoid arthritis, confirmed on physical examination and x-rays.  Notably, he also has ulnar deviations and has been started on Plaquenil, a disease modifying agent, to mitigate development of joint deformities.  Relative avoidance of activities that would continue to inflame the involved joints would be appropriate. Overall, the patient is unable to successfully resolve his mobility impairments through self-powered means such as crutches, a walker or a manual wheelchair.  He is at high-risk for untoward events such as additional falls.  His current right fifth metatarsal fracture would also be at significantly higher risk for prolonged non-healing with weight-bearing activity.  A wheelchair would be appropriate, but the patient is precluded from using a manual wheelchair due to his rheumatoid arthritis.  Powered mobility would be the most reasonable and appropriate means of mobility for this patient based on the records forwarded for review.  All told, in this patients case, the requested mobility scooter is medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the whole body skin photography provided.Findings:  The physician reviewers found that the use of whole body photography for monitoring nevi has not been demonstrated to improve the long-term outcome in patients with a history of melanoma in large clinical trials. In addition, the National Comprehensive Cancer Network (NCCN) does not recommend its use in this clinical setting. Thus, its usage is not considered to be standard of care in following an individual patients nevi. Accordingly, the whole body skin photography provided  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 service 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 1, 2, and 3 are board certified in dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne genomic analysis for evaluation of the enrollees synovial sarcoma. Findings:  2/3 of the physician reviewers found that the accessibility of this technology is directly affecting clinical practice because providers frequently encounter situations where cancers progress on standard therapies. At that juncture, usually the medical literature is consulted to select a therapy that has been tested in clinical protocols, or the patient is enrolled into an active protocol. This is the standard of care. Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study by colleagues involved patients where the progression-free survival (PFS) on the regimen selected by molecular profiling was compared to the PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. FoundationOne has developed a panel of 400 oncogenes and tumor suppressors to be tested by next generation sequencing in hematologic malignancies and sarcomas. There is support in the medical literature for the use of genetic testing to identify mutations that may be amenable to targeted therapies. In sum, FoundationOne genomic analysis was likely to have been of greater benefit for the evaluation of this patients medical condition than any available standard therapy. Final Result: 2/3 of 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL pen (two pens per 28 days).  Findings:  The physician reviewer found that (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and Dupixent is the preferred therapeutic option by dermatologists in the community. Seigels and colleagues note that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. In this case, given that the patient has a diagnosis of atopic dermatitis appears to be a good candidate for Dupixent, the requested medication is medically indicated. Therefore, Dupixent 300 mg/2 mL pen (two pens per 28 days) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 dermatology 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.