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

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient treatment for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that In this clinical setting, the services at issue were not and are not medically necessary. The patient was not a danger to himself or to others. He was medically stable and he was not on any psychiatric medications. He did not demonstrate symptoms of delusions, hallucinations, paranoia, or mania. He did experience social anxiety. He remained sober and had . There were no emotional, behavioral, cognitive, or impulsive behaviors that would warrant intensive outpatient program level of care. His activities of daily living were intact. He was actively engaged in the program and demonstrated motivation by attending four Alcoholics Anonymous meetings per week, obtaining a sponsor, working on relapse prevention, using his workbook, and completing assignments. The documentation notes that he had improved and there was no evidence to suggest that treatment at a lower level of care would exacerbate his condition or lead to a relapse. He no longer required the structured setting of multiple days per week/multiple hours per day in an intensive outpatient program level of care. He could have continued his recovery in an outpatient setting with community support in 12 step meetings, his sponsor, and other outpatient services such as counseling. For these reasons, the intensive outpatient treatment was not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are 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 psychiatry with sub-specialty certification in addiction psychiatry 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a pulmonary function test (PFT) at a tertiary level of care. Wanger and Culver report that most, if not all, hospitals and many clinics and doctor offices now have a PFT laboratory that is staffed with technicians who are trained to use the instrumentation, provide instruction to patients, and assure that quality data has been obtained. The authors further report that simple and more complex PFTs have become more accurate, faster, and more sophisticated. Given that a PFT performed at the community hospital is likely be of the same quality as that done a tertiary level of care due to the wide availability, standardization, and universal quality measures, the requested service is not medically indicated.  Therefore, a PFT at a tertiary level of care is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in pulmonary disease and in critical care 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: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested unlimited injections of viscosupplementation for treatment of her bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is a lack of support for the requested services in this patients case.  There have been carefully conducted double-blinded studies which do not document clinical effect from hyaluronan injection.  Additionally, there is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response.  This patient has had multiple injections and with each injection there is an increased risk of allergic response. There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a recent meta-analysis of the efficacy of viscosupplementation.  This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a clinically irrelevant benefit and an increased risk of serious adverse effects.  Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint.  All told, unlimited injections of viscosupplementation are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested for radiofrequency ablation (RFA) for treatment of his kidney cancer.   Findings:  Two physician reviewers found that there is no evidence submitted which documents that this patient, who is otherwise healthy, has an increased risk for standard surgery above and beyond that which is normal for his age.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing for evaluation of the enrollees malignant melanoma. Findings:  The 3 physician reviewers found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in dermatology 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 FoundationOne CDx assay. In patients with metastatic and recurrent cancer from many types of solid tumors, next generation DNA sequencing can help guide treatment. In 2017, the U.S. Food and Drug Administration (FDA) approved the FoundationOne CDx technology for analyzing pathogenic variants in solid tumors. FoundationOne CDx technology detects variations in the coding regions of over 300 genes and provide information about differences between tumor and adjacent noncancerous tissue. The FoundationOne CDx reveals genomic signatures such as microsatellite instability and tumor mutational burden. Per current recommendations, indications for FoundationOne CDx include metastatic and recurrent cancer for a number of solid tumor types as well as tumors of unknown primary, for which genomic information would inform patient management. The records reviewed demonstrate that this patient underwent this testing to guide treatment decisions for her mixed endocervical adenocarcinoma with high-grade neuroendocrine carcinoma. The utility of the FoundationOne CDx has been demonstrated to yield data that is not available with other standard testing in this clinical setting. Therefore, the FoundationOne CDx assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the FoundationOne CDx assay was likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given these findings, the patient meets the six ASAM criteria for RTC level of care services. Therefore, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in addiction 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the physician reviewer found the current medical evidence supports the requested services in this patients case. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Evidence-based, peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. This patient presents with right knee pain with associated giving way and worsening left knee pain, with bilateral loss of range of motion. Clinical examination findings are consistent with x-ray findings of tricompartmental osteoarthritis of both knees. She had failed to improve with recent corticosteroid injections and desires to delay total knee replacement. All told, the requested hyaluronan injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee requested for spinal nerve treatment (CPT codes 64635, 64636 and 77003 for treatment of her low back pain.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other alternatives.  The current medical evidence does not support the requested spinal nerve treatment in this clinical setting.  There is a lack of evidence that the patient has exhausted conservative care treatment options.  There is documentation of lumbar facet joint steroid injections.  However, diagnostic medial branch blocks are performed using only local anesthetic.   Additionally, there were no submitted imaging studies to rule out nerve root compression.  Therefore, the superior effectiveness of the requested spinal nerve treatment has not been demonstrated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 51-year-old female enrollee has requested residential treatment services for the treatment of the enrollees posttraumatic stress disorder, panic attacks and bipolar disorder. Findings:  The physician reviewer found that the patient was seriously ill at the time of admission to the residential facility. However, she clearly improved. She was no longer suicidal. Her mood was not substantively depressed, and her need for 24/7 supervision and care in a residential setting was not documented. The patient could have received all necessary psychiatric care at a lesser level of service. She could have been treated safely and effectively in a partial hospital program as of the last authorized date of service.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver related conditions. The guidelines recommend that treatment naive genotype 1a patients can be treated with Zepatier for 12 weeks when NS5A resistance is not found, as in this case. These guideline recommendations are based on clinical trial results.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  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 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

A 60-year-old male enrollee has requested oxaliplatin for the treatment of his pancreatic cancer. Findings:  Two physician reviewers found that a variety of chemotherapies have been tried as second-line therapy for pancreatic cancer (first-line remains Gemzar with or without Tarceva). None of these regimens have had dramatic benefit. However, there is data in published reports of the activity of oxaliplatinum in pancreatic cancer, both as first-line (Ghosen, et. al.) and second-line (Tsavaris, et. al.) agents. Both of these studies involved FOLFOX and did demonstrate some degree of responsiveness and clinical benefit from this combination in pancreatic cancer. As such, there is sufficient data to support the use of oxaliplatin in this setting and therefore the therapy should be approved.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female has requested Betaseron 0.3mg for treatment of her relapsing remitting mutiple sclerosis (MS). Findings: The physician reviewer found that she has relapsing remitting MS and it is medically necessary for her to be on a disease modifying drug (DMD). There is no data to suggest which of the U.S. Food and Drug Administration (FDA) approved therapies is superior as a first-line agent in this clinical setting. While the high dose-high frequency interferons Rebif and Betaseron are generally regarded to have equal efficacy, one is interferon beta 1a, and the other interferon beta 1b. In a review article by Plosker, Betaseron has the longest track record of any DMD and continues to be a good choice for first-line therapy. As Betaseron is FDA approved as a first-line agent for the treatment for relapsing forms of MS, and this patient has been doing well for two months since starting Betaseron, the requested Betaseron 0.3 mg is medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested excision of three sebaceous cysts for treatment of his sebaceous cysts. Findings:  The physician reviewer found that the patient is requesting coverage for excision of three epidermal inclusion cysts.  Based upon the submitted records, he has not had other therapies, including intralesional steroid injection for acute inflammation or incision and drainage.  The cysts are benign growths without malignant potential. Given that they are not interfering with normal function or enlarging rapidly, treatment is not considered medically indicated.  There is a lack of symptoms, such as rapid growth, pain, drainage or impeding on adjacent structures.  Thus, excision of any of the cysts is not medically necessary.  The cysts are not caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The proposed treatment is meant to create a normal appearance, as one of the cysts is located on the glabella, between the eyebrows, although the surgery is not expected to offer more than minimal improvement in the appearance of the patient.  All told, the requested procedure is not reconstructive in nature and is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin 80 mg and oxycodone 30 mg (three times per day). Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. The Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or greater MME per day, and should avoid increasing dosage to 90 or greater MME per day or carefully justify a decision to titrate dosage to 90 or greater MME per day. In the documentation available for review, no objective treatment goals for pain and function are noted for this patient to continue on the requested medications. The patient was recently taking 360 MME per day. However, no medical evidence based rationale is given for such a high dose. There has been no difference in pain scores or objective function despite decreases in the amount of opioids. Specifically, there is no improvement or change in the patients objective function with the 135 MME per day decrease. Further, no objective goals with this high of a dose of opioid has been established by the provider and increases appear to have been based on pain levels. The records suggest that tolerance has taken place since the start of the narcotics. There is also the concern for opioid induced hyperalgesia. Finally, not all non-opioid medications classes have been tried or optimized. For these reasons, the requested OxyContin 80 mg and oxycodone 30 mg (three times per day) are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications are 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.