Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient underwent genetic testing, which revealed a BRCA1 mutation of uncertain clinical significance. She has a calculated lifetime risk of 27.7% of developing breast cancer utilizing the Tyrer-Cusick model. Repeat genetic testing utilizing the International Breast Intervention Study (IBIS) model revealed the patient had a 12.3% lifetime risk of developing breast cancer. Magnetic resonance imaging of the breasts revealed no evidence of malignancy. A bilateral digital diagnostic mammogram and targeted left breast ultrasound revealed benign results and heterogeneously dense breast tissue. The patient has requested authorization and coverage for a mammogram, sonogram, and a 3D mammogram of both breasts. The Health Plan has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. At issue in this case is whether a mammogram, sonogram, and a 3D mammogram of both breasts are medically necessary for the evaluation of this patients medical condition. The breast cancer detection rate is increased with use of digital breast tomosynthesis (3D mammogram) compared with two-dimensional mammography alone. Additionally, false-positives can be decreased. The sensitivity of screening mammography is decreased in women with dense breast tissue, as cancers can be obscured by the dense tissue. In this population, a sonogram can be used to detect mammographically occult cancers. In the study found, the addition of a screening ultrasound or magnetic resonance imaging to mammography in women at increased risk of breast cancer resulted in a higher cancer detection yield. In this patients case, her calculated lifetime risk of breast cancer is greater than 20% utilizing the Tyrer-Cusick model.  This patient underwent two-dimensional mammography with targeted left breast ultrasound. At this time, screening bilateral sonogram is medically necessary. Since this patient underwent bilateral mammogram, 3D mammogram is not indicated at this time. Annual mammography and tomosynthesis will be appropriate in February 2020. Therefore, the requested sonogram of both breasts is medically necessary for the evaluation of this patient. The requested mammogram of both breasts and 3D mammogram of both breasts is not medically necessary at this time.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Guardant360 panel testing to determine the molecular status of her lung cancer and to guide next steps in medical treatment, accordingly. The enrollee is diagnosed with non-small cell lung cancer, with bone metastases. A right lung biopsy showed her cancer was epidermal growth factor receptor positive (EGFR) positive. A computerized tomography (CT) scan showed stage IV lung cancer with a mass and pulmonary nodules consistent with disease progression. Her primary adenocarcinoma was being treated with Tarceva and bone metastases were treated with Zometa. On an oncology visit, notes indicate her primary cancer had progressed with Tarceva treatment and the next step was to check for her TM 790 mutation, which would determine the course of her treatment. The Guardant360 panel genetic testing was performed and detected six total somatic alterations and a TM 790 value of 9.3. This diagnostic is a blood-based liquid biopsy that analyzes circulating tumor DNA (ctDNA). It is still in the research phase and is not the standard of care. Testing methods used to detect circulating cancer cells in enrollees with advanced non-small cell lung cancer is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines.  Literature shows that such testing can provide more specific information for secondary and last-line treatments, but there are not enough studies to support the utility of this type of testing in place of more specific genome testing.  The Guardant360 is promising technology, but one which still requires additional research and clinical trials. The validity of certain types of liquid biopsy methodologies for guiding treatment and predicting outcomes; however, the Guardant360 is not among those approved for use. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three 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: Upheld

A 25-year-old female enrollee has requested continued hospitalization for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient had no suicidal or homicidal ideation or psychosis on admission. She was not in medical jeopardy due to her eating disorder such that she required a 24-hour treatment milieu. She did need detoxification from various substances and required chemical dependency treatment but she could have reasonably been treated at a lower level of care such as chemical dependency rehabilitation treatment for her addiction. American Psychiatric Association guidelines support chemical dependency treatment for this patient as a first-line of treatment in lieu of 24-hour inpatient hospitalization.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for total disc arthroplasty with a Prestige Cervical Disc for treatment of his herniated cervical disc.   Findings:  Two physician reviewers found that cervical artificial disc replacement remains experimental for the treatment of cervical spondylosis and cervical disc herniation. More outcomes data is needed in the mid and long-term to establish the safety and efficacy of this device. Complications in the mid and long-term are not clear at this time. Artificial disc surgery is not appropriate and not likely to be more effective than cervical fusion in this case.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested Amitiza 24 mcg, twice per day for treatment of her chronic constipation.  Findings:  The physician reviewer found that the records submitted for review substantiate that this patient meets the Rome III criteria for the diagnosis of chronic constipation with symptoms persisting throughout her lifetime. The records suggest her chronic constipation has worsened and her provider has prescribed Amitiza 24 mcg twice a day to treat her chronic constipation. According to the medical literature, chronic constipation is the most common gastrointestinal complication of long-standing diabetes. Because of her diabetes, she likely has slow transit constipation. Recently, Wald published results indicating that fiber therapy (i.e. Metamucil, Citrucel, calcium polypcarbophil) will likely worsen constipation in patients with this type of condition. In addition, saline laxatives may place this patient at risk of phosphate nephropathy and renal failure due to her diabetes and a phosphate laxative is contraindicated since patients with long-standing diabetes likely have underlying kidney disease. Similarly, the recommendation that mineral oil be used to treat constipation is not standard practice. The potential complications of chronic mineral oil use include anal stenosis and, if aspirated into the lungs, lipoid pneumonia which is a potentially life-threatening condition especially in a patient with long-standing diabetes. Mineral oil is easily aspirated when ingested because it is less dense than water. Since Amitiza is appropriate given this patients co-morbid condition, the requested Amitiza 24 mcg twice daily has been established as medically necessary for management of her condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.   Findings:  Two physician reviewers found that Botox is not a first-line therapy for migraines/chronic headaches, its use has been shown to be beneficial for a select group of patients.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Optune Plus Transducers for treatment of the patients medical condition. Findings:  The physician reviewer found that the medical literature, one large multi-institutional prospective randomized controlled trial, treated recurrent glioblastoma patients with providers choice chemotherapy or the Optune device. The authors concluded that no improvement in overall survival was demonstrated, however efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma`. In the most recent National Comprehensive Cancer Network (NCCN) guidelines, Optune for newly diagnosed glioblastoma carries a category 1 recommendation. However, Optune is not mentioned for use in patients with grade 3 gliomas. In the absence of data demonstrating improved patient outcomes with use of the Optune device, the Optune Plus Transducers provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Optune Plus Transducers provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the Optune Plus Transducers provided were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested Hyalgan injections for the treatment of his advanced degenerative arthritis. Findings:  The physician reviewer found that the use of viscosupplementation in the treatment of osteoarthritis of the knee has been shown to be effective and safe, as noted by Brzusek and Petron. A series of three to five injections constitutes one treatment, depending on the particular medication utilized. In the case of Hyalgan, five injections are usual. Repeated courses of treatment may be of value if there was a good response to the initial course and a period of time, usually six months, has passed. There does not appear to be a problem with repeated courses of therapy, other than a slight increase of local adverse events. Hyalgan may also have a beneficial effect on the articular cartilage structure, as noted by Amiel and colleagues. This patient has undergone one course of treatment, with good result. Recurrent problems have been documented, and he has a history of NSAID use with evidence of intolerance. A repeated course of Hyalgan was recommended five months after the initial course. Thus, the criteria for a repeated series of Hyalgan injections are documented. Hyalgan injections were and are indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Xifaxan for treatment of the enrollees irritable bowel syndrome with diarrhea. Findings:  The physician reviewer found that the medical literature supports that Xifaxan has proven efficacy for the treatment of irritable bowel syndrome, diarrhea predominant. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. Moreover, there is data for safety and effectiveness of subsequent courses of Xifaxan, which continued to be effective.  The subsequent courses were just as effective and the effect had a similar duration.  The medication has been proven safe and effective in randomized placebo controlled trials for IBS-D (Xifaxan package insert). In the TARGET-3 trial of over 1,000 patients, Xifaxan proved effective with significant symptom improvement in irritable bowel syndrome. The patient has already attempted alternatives such as dicyclomine without success. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of this patients irritable bowel syndrome, diarrhea predominant. 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: Experimental/Investigational
Decision: Upheld

A 76-year-old male enrollee requested authorization and coverage for total ankle replacement.  The health plan has denied this request indicating that the requested treatment is considered experimental for the enrollees Musculoskeletal condition.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the medical condition than any available standard therapy.  The health plans denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old female enrollee has requested Epiduo gel for treatment of the enrollees acne. Findings:  The physician reviewer found that this patient has a history of acne. She has responded well to topical therapy with Epiduo, a combination topical agent that contains a retinoid cream (adapalene) and a topical antibacterial agent (benzoyl peroxide).  Use of both topical retinoid creams and topical antibiotics are useful and effective for acne treatment, as noted by Eichenfield and Gold. However, preferred formulary alternatives are available which have not been tried, including tretinoin and benzoyl peroxide-erythromycin. Based upon the submitted documentation, the medical necessity of Epiduo gel has not been established.  All told, Epiduo gel is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for  Schroth Method physical therapy. The records document that this patient has a history of idiopathic scoliosis in the thoracic spine. The patients provider has recommended treatment with Schroth Method physical therapy. The aim of treatment of adolescent idiopathic scoliosis is to prevent curve progression to 50 degrees, beyond which there is a risk of continued progression in adulthood. Surgery is therefore usually recommended if the curve reaches 50 degrees during adolescence. Treatment with rigid bracing has been shown to decrease the progression of high-risk curves to the threshold for surgery  and is the most widely accepted form of treatment for the prevention of curve progression. However, a portion of patients still require surgical intervention despite treatment with bracing. There is sufficient evidence to support use of physiotherapy interventions such as the Schroth Method to increase response of the curvature to bracing. The Schroth Method consists of three-dimensional principles of correction and emphasizes postural corrections throughout the day to change habitual postures and improve alignment, pain, and progression. The Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) guidelines recommend the use of physiotherapeutic scoliosis specific exercises (PSSE) as a stand-alone therapy, add-on to bracing, and during the postoperative period. Current evidence shows Schroth exercise during bracing is superior to bracing alone in improving Cobb angles, trunk rotation, and quality of life scores. Furthermore, patients who were compliant with the Schroth program had a higher rate of Cobb angle improvement. Based on the available evidence, the requested Schroth Method physical therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Schroth Method physical therapy 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 services are 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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:  The enrollee requested authorization and coverage for arthroscopic surgery for the left knee. According to the medical record, the enrollee has a history of left knee pain, for which she had previous arthroscopic partial meniscus debridement. She presented for orthopedic evaluation as her left knee pain has been worsening.  Orthopedic examination of the left knee showed pain, swelling, and decreased range of motion. The orthopedist diagnosed left knee osteoarthritis and degenerative joint disease. X-rays showed mild joint space narrowing. According to the medical literature, the majority of studies do not support the use of arthroscopic partial meniscus debridement (APM) with osteoarthritis, and even when there is no osteoarthritis.  A review of the literature indicates a study of patients with arthroscopic partial meniscus (APM) compared to sham (fake) surgery in patients with mechanical symptoms.  They found that resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking. They concluded that the mechanical symptoms do not suggest a better outcome with APM over sham surgery. Second, a larger study performed by the same group concluded that even in patients without arthritis but with a degenerative meniscus tear, APM offered no benefit over sham surgery. Finally, a recent review found that APM was only of mild benefit in patients without any OA. Thus, given the evidence of mild OA on x-rays and moderate to severe OA on MRI, with swelling, there is limited data to support the benefits of performing an arthroscopic partial meniscus debridement, even with mechanical symptoms. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Orthopedic Surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested continued rehabilitative services for treatment of her multiple traumatic injuries. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The medical records indicate the patient has progressed well, making significant gains while in inpatient rehabilitation receiving PT, OT, ST and cognitive therapies. She no longer requires an inpatient setting and can safely receive continued therapies through outpatient programs. Moreover, the patients progress report assessed by her provider and therapists note the patient is appropriate for therapy in the outpatient setting. Therefore, continued rehabilitative services was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy. The requested speech therapy is medically necessary for treatment of the patients speech and language delay. The patient has significant scatter in his evaluation scores, but on the Comprehensive Assessment of Spoken Language performed his lexical/semantic language was at the fifth percentile, and syntactical language at the fourth percentile. Moreover, evaluation using the Goldman-Fristoe Test of Articulation Third Edition revealed a standard score of 94 and percentile rank of 34. The Goldman Fristoe Test of Articulation 2 (GFTA-2) demonstrated skills at the five year, four month age equivalent. Given these scores, the requested speech therapy is supported as medically necessary for treatment of this patients speech and language delays. 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 neurology with special qualification in child neurology 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.