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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for procedure code 87486 (nucleic acid identification using direct probe, amplified probe, or quantification) she received. Findings:  Three physician reviewers found that the medical records fail to demonstrate the findings consistent with the Centers for Disease Control and Preventions definition (CDC) of Lyme disease, A systemic, tickborne disease with protean manifestations, including dermatologic, rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease is the initial skin lesion (i.e., erythema migrans {EM}) that occurs in 60%-80% of patients. Studies find There is no well accepted definition of post Lyme disease syndrome. This has contributed to confusion and controversy. There is a lack of firm data on its incidence, prevalence, and pathogenesis. In an attempt to provide a framework for future research on this subject and to reduce diagnostic ambiguity in study populations, a definition for post Lyme disease syndrome is proposed in these guidelines. According to the CDC guidelines, the patients records fail to demonstrate that she has Lyme disease or that she needed testing. For these reasons, procedure code 87486 (nucleic acid identification using direct probe, amplified probe, or quantification) that was received was not likely to have been more effective than other methods of evaluating this patients medical condition. Final Result: Three 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: All three reviewers are board certified in allergy and immunology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing. According to the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of rupture of membranes (ROM) is traditionally made based on patient history and clinical examination including a speculum evaluation of the vagina and cervix. Typically, the patient history, with its description of leakage of fluid, can help to confirm or rule out the diagnosis. This is coupled with a sterile speculum examination to provide direct visualization to evaluate for pooling, to evaluate the pH of any secretions, and to perform a microscopic examination for cervical ferning complete the examination. From a review of the medical records, this patient had a high risk course and was complaining of additional moisture and discharge. Several tests were performed including a sterile speculum examination, a swab, AmniSure testing, and a vaginal culture to evaluate for leakage of fluid. The documentation states that ferning that was performed and was negative. The description of the fluid, from the sterile speculum examination, as white and not clear, is not consistent with a diagnosis of pooling of amniotic fluid. There is no documentation of pH testing. Given the findings on sterile speculum examination, additional testing for ROM was not needed. All told, the laboratory testing was not likely to have been more beneficial for evaluation of this patients medical condition than any available testing. One reviewer found that the laboratory testing was likely to have been more beneficial for evaluation of this patients medical condition than any available testing.Final Result: Two of the three 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee has requested rituximab (Rituxan) for the treatment of his multiple sclerosis. Findings:  Two physician reviewers found that this is a patient with MS with progression of his symptoms and MRI findings despite a course of Copaxone. Although additional large-scale controlled studies need to be performed, the current literature is supportive of Rituxan for refractory multiple sclerosis. Referenced above is a small portion of the literature supporting the use of this medication for multiple sclerosis and similar disorders. Given this patients progression, initiation of Rituxan therapy is warranted under close supervision by his neurologist.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for sub-acute rehabilitative services.Nas and colleagues noted, The treatment and rehabilitation period is long, expensive and exhausting in spinal cord injury (SCI). Whether complete or incomplete, SCI rehabilitation is a long process that requires patience and motivation of the patient and relatives. Per Hagen and colleagues, Knowledge of cardiovascular sequelae after spinal cord injuries and assessment of these is important for correct diagnostics, planning of preventive measures and optimal treatment. Rosin and colleagues noted, Skin breakdown, including burns and pressure injuries (PrIs), is a devastating complication of spinal cord injury (SCI).In this case, the patient has a complicated rehabilitative history related to his spinal cord injury. The patient was appropriately transferred to acute rehabilitation for acute care for his spinal cord injury following cervical stabilization surgery. Unfortunately, the patients rehabilitation was complicated by atrial fibrillation with rapid ventricular response. Spinal cord injury patients, particularly tetraplegics, typically have newly developed cardiac complications. This complication required that the patient receive acute care for about 10 days. As a result, the patient did not receive the rehabilitation that he would have received in an acute or sub-acute rehabilitation facility. This likely set the patient back in his rehabilitation. When the patient was transferred to a skilled nursing facility, he ended up developing a stage 3 pressure sore. The notes indicate that the patient needed at least moderate assistance to perform pressure reliefs. Such wounds will not heal without consistent pressure reliefs, which would have to be performed at least every hour. Vocational nurse notes indicate that the patient needed maximum assistance for activities of daily living. The pressure sore that was developed in the skilled nursing facility will not heal without consistent pressure reliefs and wound care. The patient is at risk for further injury and complications without wound care, consistent pressure reliefs and further rehabilitation to help him better independently perform activities of daily living. Under these circumstances, the sub-acute rehabilitative services were and are medically necessary to treat the patient's medical condition.Final Result: The reviewer determined that the services at issue were and are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested residential treatment center (RTC) services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation does not demonstrate that the patient met accepted criteria for residential treatment center level of care from the date in question onward. The precipitating factors for her admission to residential treatment were aggression at home, difficulty in control of her behavior and an ongoing substance abuse issue. Based upon the documentation provided, the patient was not going through moderate to severe withdrawal. She did not show any moderate biomedical complications that would require 24 hour medical monitoring. The medical records do not demonstrate that she was or is dangerous to herself or others. The patient is able to socially function and is able to perform self-care. There is no indication from the documentation provided that the patient required the intensity of service of 24 hour supervised care during this time. Thus, the patient could be treated in a lesser restrictive environment as of the date in question.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested for Lipitor 20mg for treatment of his hypercholesterolemia. Findings:  The physician reviewer found that there is no reason the patient cannot change to another agent which may be just as effective as Lipitor. There is a lack of evidence that Lipitor will improve the patients outcome over other medications, such as Zocor. The guidelines of the American College of Cardiology do not support the use of Lipitor preferable to other lipid-lowering medications.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Retacrit (epoetin alfa-epbx) or Epogen/Procrit (epoetin alfa). Guidelines for the treatment of hemochromatosis recommend iron removal until the ferritin has fallen to 50-100 ug/L. In this case, the patients ferritin level exceeds the treatment goal despite treatment with phlebotomy and iron chelation. In addition, the patient requires treatment of iron overload to reverse cardiomyopathy. Iron removal can at least partially reverse cardiomyopathy due to iron overload. The use of erythropoietin to support hemoglobin levels during sequential phlebotomy has been effective in multiple studies. For these reasons, Retacrit (epoetin alfa-epbx) or Epogen/Procrit (epoetin alfa) was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high intensity focused ultrasound (HIFU). This patient presented with Gleason score 3+4=7 prostate cancer. Findings:  The physician reviewer found that data suggesting fewer risks for urinary incontinence and erectile dysfunction. HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. HIFU has been increasingly used for treatment of localized prostate cancer over the last decade. However, there is a lack of controlled trials available for analysis, and a paucity of long-term survival data are available. The National Comprehensive Cancer Network (NCCN) guidelines state that the panel recommends only cryosurgery and HIFU as options for radiation therapy recurrence in the absence of metastatic disease. The National Cancer Institute (NCI) does not include HIFU as one of the seven standard treatments for treatment of prostate cancer, rather it is classified under new types of treatments that are being tested in clinical trials. Furthermore, the American Society of Radiation Oncology (ASTRO) does not endorse HIFU in the treatment of or patients with prostate cancer. Therefore, the HIFU was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Findings:  Three of the three physician reviewers found the HIFU was 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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

The parent of a 15-year-old female enrollee has requested biofeedback and self-care home management training with therapeutic (group) procedures for the treatment of the enrollees hypermobility and dysautonomia. Findings:  Three physician reviewers found that this patients history documents pain since the age of six, consistent with symptoms associated with Ehlers-Danlos syndrome. The patient has not demonstrated adequate relief with prior therapies. The reduction of pain during her inpatient stay demonstrates that these modalities have been of greater benefit than previously tried therapies. In addition, although there are no studies specific to Ehlers-Danlos syndrome, there are multiple studies demonstrating pain reduction with these modalities in other disorders, such as chronic pain and spinal cord injury. Biofeedback and self-care home management training with therapeutic (group) procedures were medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR hydrogel procedure. This patient presents with Gleason 4+4 and Gleason 4+3 prostate cancer. His provider has recommended radiation therapy with the use of SpaceOAR hydrogel placement to minimize toxicity to surrounding normal tissue. SpaceOAR hydrogel has been demonstrated to minimize the risk for radiation-induced rectal, urinary, and sexual toxicity per high quality prospective randomized clinical trial outcomes published in the peer-reviewed medical literature. SpaceOAR is widely utilized throughout the radiation oncology community for patients with a clinical presentation similar to this patient. Moreover, SpaceOAR is supported by the National Comprehensive Cancer Network (NCCN) guideline for the management of prostate cancer. All told, the requested SpaceOAR hydrogel procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested SpaceOAR hydrogel procedure 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were not likely to have been of greater benefit than other alternatives.  The peer-reviewed literature has not demonstrated the superior effectiveness of breast tomosynthesis compared to currently available techniques.  Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in this clinical setting.  All told, digital breast tomosynthesis was not likely to have been more effective than other modalities. Final Result:  Two 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: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing for evaluation of her behavioral health conditions. Findings:  Three physician reviewers found that in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  Indeed, trusted psychiatric reference texts do not recommend genetic testing for cases involving routine medication management.  Further, the American Psychiatric Association (APA) did not endorse such testing in a recent official statement or its most current clinical practice guidelines. There is a lack of well-designed or adequately powered studies illustrating consistent and reproducible results that provide clinically useful information pertaining to genomic testing and its relationship to specific pharmacologic interventions.  In this patients case, there was no clinical data provided to support genetic testing.  Notably absent was a psychiatric evaluation and/or interpretative summary addressing the longitudinal illness burden and extent of impairment, family history, psychosocial stressors, substance use history and possible medical comorbidities. There was no discussion of prior interventions used to treat the depression, intrusive thoughts and repetitive behaviors. 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: Reviewers 1, 2, and 3 are board certified in psychiatry 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

A 28-year-old male enrollee requested authorization and coverage of an ear, nose, and throat (ENT) consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested consultation is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male has requested coverage for a past PET scan performed for evaluation of his cognitive dysfunction.  Findings:  Two physician reviewers found that the patient presents with a history of cognitive problems.  The submitted documentation noted difficulties with planning, tracking, and follow-up of information.  The patients symptoms have reportedly impacted his employment.  As part of his evaluation, the patient received an MRI of the brain approximately fifteen months ago.  The MRI report noted no findings to explain the patients neurological symptoms.  A PET scan was performed three months later.  Complaints of cognitive dysfunction are common in men and women in their 50s and 60s. In the absence of gross cognitive deficits as determined with common cognitive tools such as the Mini Mental State Examination (MMSE), formal neuropsychological testing is widely used and is the most sensitive modality to detect mild cognitive impairment.  PET imaging may be beneficial only to differentiate frontotemporal dementia from Alzheimers disease, and not as a diagnostic test for dementia.  In this patients case, the diagnostic procedure at issue was not likely to be more efficacious than standard testing for evaluating his condition.  The current medical evidence does not support the diagnostic procedure at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-month-old female enrollee has requested  for two (2) back-up processors (one for each ear) for her cochlear implants for treatment of the enrollees congenital deafness. Findings:  The physician reviewer found that the medical literature supports binaural cochlear implantation to allow sound direction localization and to improve understanding of language in the presence of background noise. However, there is no support within the current published peer-reviewed medical literature showing that language deficits can result from the absence of binaural hearing (see Nittrouer and colleagues and Geers). In addition, there is no published evidence that bilateral implantation enhances language development, and there is no support for the contention that brief absence of hearing in one ear, caused by the failure of one processor, would compromise language development (see Geers). While it is unlikely that both processors would fail simultaneously, even if this were to occur, there is no support within the peer-reviewed published medical literature for the contention that absence of hearing for a brief period would compromise language development.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested radiofrequency ablation for treatment of his pain.  Findings:  Three physician reviewers found that this patient has chronic neck, thoracic, and lumbar pain.  The current medical evidence does not support the requested services in this clinical setting.  The submitted documentation lacks findings supporting the diagnosis of intercostal neuritis.  The clinical notes indicate that this patient has been experiencing predominantly spine pain.  Therefore, the requested radiofrequency ablation is not likely to be of greater efficacy than other treatment options for this patients pain.