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 assay provided for evaluation of the enrollees malignant melanoma. Findings:  The 3 physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system as discussed by the American Joint Committee on Cancer (AJCC). As per this system, this patient would have been stage 1b, with an expected 10-year survival of at least 83%. DecisionDx is a study of 31 genes in melanoma cells which classifies the particular melanoma as either Class 1 with a five year distant-disease free survival of 73%, or Class 2 with five year disease-free survival of 46%. Colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx classification in patients who had sentinel node biopsy. However, it has not been demonstrated how the five year DecisionDx data compares to the 10-year AJCC data, and whether it can be used to make clinical decisions. Further, the National Comprehensive Cancer Network (NCCN) guidelines state there is interest in these newer genetic profiles, but only in the context of a clinical trial. Therefore, the DecisionDx melanoma assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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 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

The patient has requested reimbursement for the removal of implants and lift that was completed. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of the patient and were not reconstructive in nature. The California Health and Safety Code requires health insurers to cover reconstructive surgeries. This is defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to either improve function or create a normal appearance to the extent possible. The medical records support that the bilateral removal and capsulectomy that were completed were medical necessary and considered reconstructive in nature. With regard to the requested breast lift (mastopexy), the records failed to support that the lift was medically necessary and reconstructive in nature. Final Result: The reviewer determined that some of the requested services were medically necessary for treatment of the patients medical condition and some of the services were not medically necessary. Therefore, the Health Plans denial should be partially overturned.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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral for evaluation to an intestinal transplant program. Current guidelines recommend intestinal transplantation in patients with ultrashort bowel syndrome, defined as having residual bowel measuring 20 cm and patients with unwillingness to accept long-term total parenteral nutrition (TPN). This patient has a history of total enterectomy with ultrashort bowel as well as a desire to end TPN as her source of intake. The use of intestinal transplant can result in rapid return of the patients nutritional autonomy, and avoid complications of TPN such as bacteremia or sepsis, fluid and electrolyte imbalances, liver and bile duct disease, and bone disease. Moreover, this patient does not have any reports of significant ongoing renal dysfunction. Given these findings, the requested referral for evaluation to an intestinal transplant program is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: Experimental/Investigational
Decision: Upheld

A 27-year-old female enrollee has requested embolization of the ovarian vein and internal iliac veins for treatment of her pelvic congestion syndrome.  Findings:  Three physician reviewers found that pelvic congestion syndrome (PCS) is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. The etiology of PCS is unclear and the optimum treatment is uncertain. Development of an evidence-based approach to managing this condition has been limited by the absence of definitive diagnostic criteria. There are no definitive diagnostic criteria for PCS. In general, the diagnosis is based on a combination of characteristic symptoms, tenderness on physical examination, and documentation of pelvic vein dilatation or incompetence, after exclusion of other causes for these nonspecific findings. The documentation provided does not demonstrate that the patient has been fully evaluated or given alternative therapy prior to the recommendation of embolization therapy.. This patient may have PCS and may benefit from embolization therapy, however it is not clear that she has been fully evaluated per the records available for review, nor is there clear evidence that other therapies have been tried. Embolization has only been shown to be of benefit in selected cases and there is an inherent risk of the loss of ovarian function with this procedure. In sum, without clear evidence of a diagnostic work up and failed attempts at conservative therapies, this procedure is not likely to be more beneficial for treatment of this patients medical condition than any other standard treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested percutaneous tibial nerve stimulation for treatment of her interstitial cystitis and urinary urgency.   Findings:  Two physician reviewers found that posterior tibial nerve stimulation is a therapy that involves electrical stimulation to a nerve in the lower leg to try to affect bladder function/symptomatology, also called neuromodulation. The Journal of Urology states that neuromodulation therapy incorporates electrical stimulation to target specific nerves that control bladder function. The specific mechanism of action is unknown but it is postulated that neuromodulation may have a direct effect on the bladder or a central effect on the micturition centers of the brain.  Sacral nerve stimulation/interstim is another FDA approved treatment for urinary urgency, frequency, urge incontinence and nonobstructive urinary retention. The Journal of Urology goes on to state that percutaneous tibial nerve stimulation (PTNS) delivers neuromodulation to the pelvic floor through the S2-S4 junction of the sacral nerve plexus via the less invasive route of the posterior tibial nerve. PTNS has been proposed as an alternate treatment to InterStim for urge incontinence and associated symptoms, and there is now substantial literature support of efficacy, in well-controlled studies. Most of the studies have related to treatment for overactive bladder.  In this case, this patient has been labeled as having interstitial cystitis, though she also has symptoms suggestive of overactive bladder. A study by Zhao, et al. concluded that intermittent percutaneous posterior tibial nerve stimulation might be an alternative treatment for patients with interstitial cystitis symptoms. This patient has had a marked improvement in her symptomatology using PTNS.  The current literature is extensive and PTNS is a well accepted therapy. Additionally, this patients positive response to treatment would support the need for ongoing coverage of this treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for endoluminal ablation of varicose veins. Findings: The physician reviewer found that in this case, there is no evidence of significant venous reflux in the GSV distribution. While there is some evidence of some reflux, a recent ultrasound did not demonstrate blood flow greater than the required threshold at the saphenofemoral junction. Therefore, the requested endoluminal ablation of varicose veins is not medically necessary. Final Result: The reviewer determined that the requested service 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 general surgery and vascular 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: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Tepezza (initial dose of 10 mg/kg followed by 20 mg/kg every three weeks for seven additional infusions). Treatment with teprotumumab (Tepezza) for the patients exophthalmos is medically necessary based on medical records supporting a diagnosis of dysthyroid orbitopathy with associated diplopia and documented failure of surgical treatment. There is no reported contraindication for use of Tepezza in patients with previous surgery. Markham noted that Tepezza is a monoclonal antibody insulin-like growth factor-I receptor (IGF-IR) antagonist developed for the treatment of thyroid eye disease (Graves ophthalmopathy/orbitopathy, thyroid-associated ophthalmopathy). Douglas and colleagues concluded that, Among patients with active thyroid eye disease, teprotumumab resulted in better outcomes with respect to proptosis, Clinical Activity Score, diplopia, and quality of life than placebo. Overall, Tepezza has been shown to be beneficial and safe for patients with acute and active orbital inflammation related to dysthyroid orbital disease. Given these findings, the requested Tepezza (initial dose of 10 mg/kg followed by 20 mg/kg every three weeks for seven additional infusions) is medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a panel of genetic hereditary cancer tests (MyRisk `Colaris` testing) for evaluation of her further risk of cancer.  Findings:  Two physician reviewers found that this patient has both breast and endometrial cancer and a strong family history of breast cancer. She has tested negative for BRCA and pathology shows a low likelihood of Lynch syndrome. Panel testing is supported by the National Comprehensive Cancer Network (NCCN) guidelines for patients such as in this case. There is also a role for multi-gene testing in individuals who have tested negative (indeterminate) for a single syndrome, but whose personal or family history remains strongly suggestive of an inherited susceptibility. All told, this patient is likely to benefit from the panel of genetic hereditary cancer tests with MyRisk. For the reasons provided, the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Two reviewers determined that the requested testing is 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified in medical oncology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Wegovy 1 mg/0.5 mL auto-injector.Gadde and colleagues indicate that obesity is associated with increased risk of numerous chronic diseases including type 2 diabetes (T2D), hypertension, and cardiovascular disease. Additionally, the authors state, Weight loss of 510% results in improvements in cardiometabolic risk factors. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. Kushner and colleagues state that semaglutide promotes weight loss by reducing energy intake, increasing satiety and satiation, and reducing hunger, as well as enhancing glycemic control. A study by Friedrichsen and colleagues found, In adults with obesity, once-weekly semaglutide 2.4 mg suppressed appetite, improved control of eating, and reduced food cravings, ad libitum energy intake and body weight versus placebo. In the study, body weight was reduced by 9.9% (10.4 kg) from baseline to week 20, in the absence of structured dietary and exercise intervention, compared with almost no change in the placebo group. In this case, the patient has been diagnosed with morbid obesity. The patients last recorded BMI was 35.35 kg/m2. Therefore, the Wegovy 1 mg/0.5 mL auto-injector is medically necessary for treatment of the patients medical condition.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 endocrinology, diabetes, and metabolism 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 35-year-old male enrollee has requested a computed tomography (CT) scan of the thoracic spine with myelogram for an evaluation of his back pain. Findings:  The physician reviewer found that the differential diagnosis of this patients thoracic radicular pain includes nerve root impingement from lateral recess stenosis. He has documented thoracic osteophytes which could cause nerve root pain. Although the MRI is normal, a CT with myelogram of the area is more sensitive in picking up nerve root compression from osteophytes as noted by Wilkins and Rengachary. The MRI does not visualize bone as well as the CT scan. Since this patient has a debilitating pain syndrome, it is medically appropriate to attempt to rule out a surgically correctable cause of this pain. Osborne and colleagues concluded that CT is an important additional investigational tool in patients with a painful radiculopathy syndrome.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Skaane and colleagues reported that the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.   Final Result: Two 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:   All three reviewers are board certified in diagnostic radiology 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 30-year-old male enrollee has requested partial hospitalization program treatment for treatment of his behavioral health condition. Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) is an evidence-based and objective instrument which is used to determine the necessary level of psychiatric care in the least restrictive setting possible. According to LOCUS criteria, as of the admission date, the patient scores as follows: 1) Risk of harm- moderate; 2) Functional status-moderate; 3) Medical, Addictive and Psychiatric Co-Morbidity - major; 4A) Recovery environment - moderate; 4B) Recovery environment, level of support  supportive; 5) Treatment and Recovery history- poor, and; 6) Engagement and Recovery Status - positive. This gives him a composite score of 21 which correlates with a treatment intensity level of medically monitored non-residential services. An example of this placement, per the LOCUS, is a partial hospitalization program. Furthermore, the patient met American Psychiatric Association guidelines for placement in a PHP during the period at issue. Specifically, he required intensive care, but had a reasonable probability of refraining from illicit use of substances outside a restricted setting; he remained at high-risk for relapse; and he was thought to lack sufficient motivation to continue in outpatient treatment. In summary, due to the patients past treatment failures, the excessive amounts of alcohol consumed, and the use of intravenous drugs, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for hereditary hearing loss deficiency deafness panel. Autosomal recessive hearing loss and other defects of the inner ear have been associated with specific genes. Researchers noted that in syndromic hearing loss, it is important to determine the syndrome and gene mutation, which can impact treatment and vital structures such as the kidneys, heart, and thyroid. This patient presents with bilateral hearing loss. His providers have recommended genetic testing. Certain syndromes are actionable, and a diagnosis would affect the patients health if revealed through the requested hereditary hearing loss panel. Accordingly, the requested hereditary hearing loss deficiency deafness panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested hereditary hearing loss deficiency deafness panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 otolaryngology 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.