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

The parent of a 13-year-old male enrollee has requested a DynaVox Communication System (with carrying case)for treatment of the enrollees communication issues. Findings:  The physician reviewer found that in this patients clinical situation, the DynaVox device is medically necessary. This patient faces significant barriers to effective communication in educational, social, and home situations because of disabilities resulting from congenital brain injury and seizure disorder. Augmentative and Alternative Communication (AAC)technology will allow him to overcome some of these barriers by providing an alternate means of communication. He has been successfully using a voice output device at school. Comprehensive evaluation has demonstrated that the patient has an adequate ability to use an AAC device, specifically the DynaVox. In addition, this device has been determined to be the best fit for him to optimize his communication skills. Without such a device, he will not be able to achieve his full potential, or maximize his independence. The literature supports the use of such communication devices for individuals like this patient. In one study, 86% of the study subjects showed gains in speech with AAC intervention (Millar).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee enrollee has requested authorization and coverage for private duty nursing in the home setting necessary for treatment of the enrollees mitochondrial disease. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested private duty nursing in the home setting. According to the American Academy of Pediatrics (AAP) guidelines for home care of infants, children, and adolescents with chronic disease comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens. AAP guidelines further state that the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. In this case, the patient is extremely fragile with a complex medically history, and she has a number of skilled nursing needs as described above. It would be neither safe nor reasonable to have her parents to tend to all of her medical needs round the clock. This patient requires constant monitoring and diligent observation to maintain health and prevent unnecessary sequelae. Skilled nursing expertise is essential for rapid identification of problems with appropriate and safe intervention. Therefore, the requested private duty nursing hours in the home setting is medically necessary and appropriate for treatment of the patients medical condition.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 physician reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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

A 29-year-old female enrollee has requested for bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that the documentation indicates that the patient has a transient BMI fluctuating between 38 and 40. There is no documentation that the patient has significant co-morbid conditions such as diabetes, hypertension or sleep apnea. Thus, the patient does not meet the National Institutes for Health standard guidelines for bariatric surgery. Given the patients transient BMI and the absence of significant co-morbidities, the patient may respond to further attempts at supervised weight loss. As such, the medical necessity of bariatric surgery for treatment of the patients obesity has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested Botox injections  for treatment of her pelvic floor pain.   Findings:  Two physician reviewers found that Botulinum toxin (Botox) injections have been proposed as a treatment for chronic pelvic pain. However, large placebo controlled and comparative trials are needed to evaluate the efficacy of single and repeat injections, the duration of effect, the optimal dosage and injection technique, the timing for repeat injection, and the short and long-term safety of the treatment of pelvic floor disorders. A study of Botox by Apostolidis and colleagues found that existing evidence is inconclusive for recommendations for in neurogenic detrusor-sphincter dyssynergia, bladder pain syndrome, prostate diseases, and pelvic-floor disorders. Based on the currently available evidence, Botox remains of unproven efficacy at this time for the treatment of pelvic floor pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for DecisionDx-Melanoma testing. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees melanoma.Findings:  Two out of three physician reviewers found that this patient has an early stage melanoma. The National Comprehensive Care 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 is a lack of definitive data regarding its use 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 a clinical trial. Should the patient have high-risk results, treatment and surveillance recommendations would unlikely be altered. One physician reviewer found that the risk classification provided by this test can be used to better estimate an individuals risk for recurrence and therefore aid in determining the most appropriate surveillance methodology and frequency.Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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: Overturned

A 41-year-old male enrollee has requested magnetic resonance imaging (MRI) for evaluation of his left arm pain.  Findings:  The physician reviewer found that MRI of the brachial plexus is a standard test used in assessing brachial plexus pathology. According to Sureka and colleagues, Magnetic resonance imaging (MRI) has become the primary imaging technique in the evaluation of brachial plexus pathology, and plays an important role in the identification, localization, and characterization of the cause. The patients history is suggestive of neuroma formation. A high quality neurogram of the brachial plexus may identify a lesion and its location, allowing the treating physicians to develop an effective treatment plan. Moreover, the requested diagnostic procedure may lead to a definitive diagnosis. In sum, the MRI of the brachial plexus pre and post contrast is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested the prescription medication Provigil for the treatment of her depression and daytime somnolence. Findings:  The physician reviewer found that providing a supplemental medication to relieve these symptoms is appropriate. Ritalin and Dexedrine were limited in their efficacy and were not well tolerated. In contrast, the patient responded well to Provigil without the nervousness she experienced with the other stimulants. Provigil is known to be a useful adjunct in the treatment of depression within the psychiatric community, and continued treatment with this medication is clearly indicated in this instance.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested Xyrem for the treatment of insomnia.  Findings:  The physician reviewer found that Xyrem is gamma hydroxybutyrate or GHB. GHB has been an effective therapeutic intervention that not only has allowed the patient to sleep, but has decreased the polypharmacy. Furthermore, there is a treatment plan in place for behavioral modification in conjunction with the drug therapy, which provides for future weaning of the medication.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old male enrollee has requested for Sutent for treatment of his metastatic extra-adrenal paraganglioma. Findings:  Two physician reviewers found that Sutent is one of a newer class of drugs that acts as an inhibitor of vascular endothelial growth factor (VEGF) as well as other factors. It has been approved for use in renal cancer and gastrointestinal stromal tumors. Malignant paragangliomas tend to be very hypervascular and strongly express VEGF. It is a very rare tumor, so there is little data relevant to its treatment, especially with regards to chemotherapy for metastatic disease. There have been sporadic responses reported to a variety of agents. In the report by Joshua and colleagues, three such patients were treated, with the development of a near complete remission in one, and partial responses in the two others. The Hahn report notes some degree of response to Sutent in one such patient. There is a lack of data regarding the treatment of this patients disease due to its rarity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan (rituximab). chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired, immune-mediated neuropathy affecting peripheral nerves and nerve roots.  Medical literatures note that first-line therapies include intravenous immunoglobulin (IVIg), corticosteroids, and plasma exchange. In this case, while the records note that the patient has inadequate response to IVIg, the records do not document adverse effects or poor clinical response to plasma exchange and steroids. CIDP is not an approved indication for the use of Rituxan by the U.S. Food and Drug Administration (FDA) and there is a lack of evidence in current medical literature supporting its use in this clinical setting. Given that the records do not document that this patient has tried and failed first-line therapies, the requested medication is not medically indicated. Therefore, Rituxan (rituximab) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in vascular 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous rituximab for treatment of her medical condition. Findings: Two reviewers found that there is sufficient support for the requested medication in this clinical setting.  This patient has refractory myasthenia gravis.  She is already on a very aggressive regimen with immunosuppression and intravenous immune globulin.  Rituximab has been used for myasthenia gravis for a number of years, and it is currently recommended for patients with refractory disease.  Given the significant literature about the use of rituximab in refractory patients, like this patient, and given her currently non-optimal disease control despite very aggressive therapy, intravenous rituximab is likely to be superior over other treatment options.Final Result: Two reviewers determined that the requested medication 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: All three reviewers are board certified in neurology 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 forty-nine year-old male with a history of recurrent glioblastoma multiforme (GBM) is requesting authorization of treatment with erlotinib (Tarceva).   Reviewers Findings:  The reviewing physician found that Tarceva has been studied in recurrent GBM. Several phase I and II studies have reported modest activity with Tarceva either as monotherapy or in combination with other agents.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old male has requested a magnetoencephalogram (MEG) for the evaluation of epilepsy.  Findings:  Three physician reviewers found that review of the relevant scientific literature demonstrates that MEG may yield information helpful in localization of seizure focus in patients such as this patient. He had exhausted other standard modalities available in this setting. The requested MEG is likely to result in sufficient information in this case to allow for surgical planning.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the her medical condition. Findings: Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her exam been done with two-dimensional imaging alone.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 physician 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: Overturned

An enrollee has requested reimbursement for the surgical procedure on the left toe. Clinical examination and operative findings were consistent with advanced hallux rigidus. She underwent placement of left first MPJ joint implant with complete resolution of her symptoms and functional restoration. The evidence-based medical literature supports the use of the joint implant as an option in this patients medical condition to maintain first MPJ motion. Given this patients age and desire to maintain first MPJ motion, the use of the implant was indicated over fusion. Therefore, the surgical procedure on the left toe was 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 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 orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a fourteen year-old male who has a bone age of eleven years and six months are requesting authorization for growth hormone therapy.  Reviewers Findings:The reviewing physician found that the growth hormone therapy is not medically necessary for treatment of the patients medical condition.  The physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys for treatment of the enrollees rheumatoid arthritis, psoriatic arthritis, severe degenerative arthrosis, bilateral knee pain, and degenerative lumbar disc disease.  The physician reviewer found that according to the U.S. Food and Drug Administration, Subsys is currently approved for treatment of breakthrough cancer pain in adult patients who are receiving and who are tolerant to opioids during the management of underlying persistent cancer pain. Additionally, Rauck and colleagues found that fentanyl sublingual spray results in effective treatment of breakthrough cancer pain, with a rapid onset of action that is well tolerated. Similarly, the National Comprehensive Cancer Network (NCCN) guidelines state that the use of sublingual formulations of fentanyl is considered an effective option for managing episodic breakthrough cancer pain. However, there is a lack of published medical literature supporting the use of Subsys for the treatment of breakthrough pain in cases not associated with cancer. This patients most recent clinical note indicated that the current medication regimen which did not include Subsys was effective. Without clinical trials demonstrating the long-term safety and efficacy of Subsys for breakthrough pain not related to cancer, the requested Subsys is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma gene expression classifier for evaluation of his thyroid nodule. Findings:  Three physician reviewers found that while FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma thyroid FNA analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy. As the Afirma gene expression classifier is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude unnecessary surgical procedures. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A 64-year-old female enrollee has requested the use of the Advanced Bionics Boston Scientific Stimulator (as opposed to a Medtronics Stimulator) for the treatment of her right foot pain. Findings:  Two physician reviewers found that the medical literature in a situation such as this is very limited, as this is an individualized situation. Specifically, this patient has both benefited from spinal cord stimulation in the past, but had a technical failure of the device. The standard of care indicates that a broad degree of discretion is appropriate with regard to the patients treating practitioners management of this condition. In this case, her provider has documented an interventional pain medicine consultation in which he outlines both a clinical and a technical/engineering rationale for the request for a specific model/brand stimulator, specifically the Advanced Bionics Boston Scientific Stimulator with a narrow-space lead and constant current system. Given the patients previous experience with spinal cord stimulation, the providers rationale for recommending the proposed device is medically reasonable and appropriate. The patient is likely to experience better results with the Advanced Bionics Boston Scientific Stimulator than with the Medtronics device.