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

Nature of Statutory Criteria/Case Summary:  An enrollee requested a positron emission tomography (PET) scan for evaluation of his cavitary left lower lobe lung mass suspicious for malignancy.  Findings:  Two physician reviewers found that although PET is not the best modality to determine whether this mass is cancer or infection, in this circumstance, the mass is highly suspicious for cancer. Thus, the utility of the requested PET scan would be in staging this patients lung cancer. Further, the PET scan will help evaluate the patient for hilar or mediastinal lymph nodes with high metabolic uptake, suggestive of metastases. Moreover, many lung metastases with cavitary lesions are from the head and neck, which would also be evaluated with the requested PET scan. All told, the peer-reviewed medical literature supports the requested PET scan as 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 diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high frequency chest wall oscillation device (inCourage Airway Clearance System) for treatment of the enrollees bronchiectasis.  Findings:  Two physician reviewers found that the management of bronchiectasis is dependent upon the etiology. The vast majority of modern literature focuses on the cystic fibrosis cohort of patients. This body of data, though, has not translated over to the less studied non-cystic fibrosis bronchiectasis patients and many of these therapies are utilized in the management of these patients even though literature is sparse. The medical literature comparing HFCWO to standard airway clearance techniques has demonstrated an improvement in quality of life and patient comfort with HFCWO and a trend in reduction of expectorated sputum. A study attempted to find the most efficacious technique for airway clearance in non-cystic fibrosis bronchiectasis and compared HFCWO to more traditional methods of chest physiotherapy. The HFCWO and airway clearance groups had similar improvements in quality of life, but the HFCWO group showed significant improvement in respiratory physiology, blood inflammatory mediators and dyspnea when compared with the standard therapy with airway clearance group. In sum, airway clearance plays a role in the management of non-cystic fibrosis bronchiectasis. Due to the advanced nature of the patients lung disease and her frequent exacerbations, a HFCWO vest is indicated for this patient. Given that the patient has been assessed with the InCourage device and reports improvement in breathing and sleeping, the HFCWO device (inCourage Airway Clearance System) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Gene Assay testing.Findings:  Three physician reviewers found that this patient had an early stage melanoma. National Comprehensive Cancer Network (NCCN) guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In addition, there are no definitive data regarding the use of gene expression profiling for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Accordingly, the DecisionDx-Melanoma Gene Assay testing services were not likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld

A 55-year-old female enrollee has requested quaternary care for treatment of her scleroderma and respiratory distress.  Findings:  The physician reviewer found that as noted by Boin and Wigley, the key to current management of scleroderma is to not isolate treatment to one problem that seems to be dominant, but to appreciate the complexity and dynamics of this multisystem disease. It is clear that use of just one drug is not effective in managing scleroderma, and that long-term therapy is required with possible adjustments based on specific clinical circumstances. A combination therapy approach that attempts to treat the immune response, the vascular disease, and the underlying tissue fibrosis is recommended. It is possible that the patient has myocardial inflammation which could be treated with immunosuppression. The degree of activity of the interstitial lung disease is also unclear, and immunosuppression might be indicated for this manifestation of scleroderma as well. It does not appear that the patient is currently being followed by a rheumatologist.The care provided by the pulmonary service in the intensive care unit appears to be appropriate with respect to acute treatment of the patients congestive heart failure and pulmonary hypertension; however, the submitted documentation does not demonstrate that treatment of the patients underlying disease is currently being addressed. The Health Plan indicates a rheumatology consultation is being arranged for the patient. Evaluation and assessment by a rheumatologist is medically reasonable and appropriate in order to determine available options for treatment of the patients systemic disease. Based upon the clinical evidence available at this time, the medical necessity of quaternary services is not currently supported.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested speech and language therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the articles by Law and colleagues, and Goorhuis-Brouwer and Knijff, both emphasize the need for speech therapy in young patients with this degree of impairment, and the efficacy of speech therapy in this population. Moreover, Prelock and colleagues explored the burden of speech dysfunction and quantified the need for speech therapy in the school-aged patient. The available records suggest that this patient was having academic difficulties in speech and coordinative activities at school a few years ago. The diagnosis of ADD suggests the patient has a congenital disorder of learning and speech that was apparently not identified until a few years ago. Typically, patients with ADD have difficulties in learning and focus, without the additional burden of hyperactivity. Nevertheless, this patients difficulties with speech showed vast improvement utilizing the measurements of the Listening Wheel as a result of therapy. Given this patients congenital disorder of speech impairment, speech and language therapy was clinically indicated during the time period at issue. The documented improvement in his level of function only further confirms the medical need for the speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight weeks. According to recent guidelines, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1b patients should be treated with Mavyret for eight weeks. This recommendation is based on multiple high quality clinical trials showing cure rates of over 90%, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  Guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Mavyret 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

The patient is a 29-year-old female who was found to have a tear in her left labia five months postpartum. The defect was noted on the exam of February 2004 and there is no documentation in a prior exam that the patient had been aware of it or that it had caused her pain or dyspareunia. The delivery note of 9/14/04 does indicate that the patient had sustained a left labial tear at delivery and that it had been repaired at that time. A request has been made for authorization for repair of the hole in the patients labia. The Health Plan indicates the requested services are not medically necessary for treatment of the patients medical condition.Labial tears and subsequent suboptimal healing are known and accepted risks associated with vaginal deliveries. Review of the records provided does not demonstrate that repair of the labial tear is medically necessary. There is no evidence the patient is experiencing pain or dyspareunia. As such, there is no medical justification for the requested procedure. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 60 x 6 mg/0.5 ml sumatriptan injections per month for the treatment of the enrollees severe cluster headaches. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication quantity. This patient has had trials of several different medications reasonably expected to improve headache frequency and severity for the diagnosis of chronic cluster headaches, with thus far unremarkable results. The patients provider correctly noted that that sumatriptan can be safely used on a daily basis for the treatment of chronic cluster headaches.  Per the records, this has been the only effective treatment for this patient.  There are no safety concerns regarding this treatment based on literature review. The medical evidence supports the requested medication quantity in this setting. Final Results: The reviewer determined that the requested medication quantity 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a Registered Nurse (RN). This patients clinical studies and physical examination findings support a diagnosis of trifecta syndrome as noted by her provider. As described in the literature, this is an autoimmune disease with multiple components including chronic mast cell activation with dysregulated chronic inflammation. Postural orthostatic tachycardia syndrome (POTS) is related to autoimmunity and is considered an autoimmune disease due to dysregulated antibody production. This patients clinical evaluation and diagnostic studies support an underlying pathologic process of autoimmunity, dysregulated inflammation, and immune deficiency with high risk for recurrent infections. The use of IVIG has been demonstrated to be safe and effective for a variety of autoimmune and inflammatory diseases. Based on the patients diagnosis and clinical presentation, Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a RN is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a RN is likely to be more beneficial for treatment of the patients medical condition.Final Result: The reviewers determined that the Gammagard 24 grams divided into three (3) doses over five (5) days every four (4) weeks to be infused by a RN is likely to be more beneficial for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in pediatric oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in oncology with expertise in hematologic malignancies and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in pediatric oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the immunology test rendered. The Health Plan has denied this request as investigational for treatment and evaluation of the enrollees condition. Findings:  The immune cell function assay testing, also known as ImmuKnow is considered beneficial and clinically relevant in the case of this patients condition. The patient is status post kidney transplantation and she has chronic autoimmune medical conditions, which include multiple sclerosis and systemic lupus erythematosus. There was a clear clinical need to measure or monitor the patients level of immune suppression with a validated FDA-approved test such as ImmuKnow. Clinical studies and current peer-reviewed literature support its use. ImmuKnow has shown to be a useful non-invasive biomarker for monitoring cellular immune function for transplant recipients, a valid tool for determining risk of further infection or rejection, and a test that can optimize overall outcomes following organ transplantation.Final Result: Two of the three reviewers determined that 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 overturned.Credentials/QualificationsAll three reviewers are board certified in internal medicine with a sub-specialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 60 Percocet every month for treatment of the enrollees chronic neck/back pain, and migraines. Findings:  The physician reviewer found that the submitted documentation supports the requested medication for treatment of this patient. Percocet is an analgesic, taken as needed, for the treatment of moderate to severe chronic pain. The patients medical record demonstrates a history of chronic back and neck pain.  This patient endorses analgesia with Percocet and denies adverse side effects. The patient reports improvement in his activities of daily living when on this medication. The patient reported that he has tried and failed other therapies for the treatment of his pain, and Percocet was the most effective. Sixty tablets of Percocet every month is well within the normal standard prescribed for this medication. The medication can be taken twice per day, thus for a 30 day period of time, a prescription for 60 tablets is medically appropriate. The medical literature supports 60 tablets as a low dose regimen and would not be considered a large quantity of medication dispensed on a monthly basis. Furthermore, the records did not indicate that the patient displayed aberrant behavior while on this medication. As such, the requested medication is medically appropriate for treatment of this patients chronic pain. 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 anesthesiology 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 parent of a nine-year-old male has requested speech therapy, three times per week, for 60 minutes per session for treatment of his autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for the treatment of this patient.  The medical records document a history of expressive and receptive language delays with phonological deficits.  Language deficits are one of the core aspects of autism, and speech therapy provides assistance with communication development for individuals with autism.  The development of language skills is necessary in this clinical setting.  This patient will benefit from speech therapy as part of a dedicated intervention program.  The current medical evidence supports speech therapy as an effective intervention in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings:  Two of the three physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.   Although the results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Thus, advanced lipoprotein testing was not likely to have been more effective than other methods of evaluating this patient.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 upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 55-year-old female enrollee has requested a third series of bilateral Euflexxa injections for treatment of herv bilateral knee osteoarthritis.   Findings:  Two physician reviewers found that the patient meets criteria for the requested viscosupplementation treatment including failure of other therapies and a period of more than six months since her last treatment. There is documented evidenced based improvement seen with these injections (Bellamy and colleagues). The authors in this study concluded that although their small sample size precluded definitive comment on the safety of the therapy, overall they found support for the use of viscosupplementation with hyaluronan and hylan derivatives in the treatment of knee osteoarthritis. Since this patient has already experienced positive results with this therapy in the past, has failed alternative treatment modalities, and received her most recent course of viscosupplementation more than six months ago, the requested therapy is medically reasonable and appropriate for treatment of her condition and should be authorized.