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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Tempus Gene Panel. This patient presents with a history of grade IV glioblastoma multiforme. Central nervous system (CNS) tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics. Glioblastoma multiforme is a high-grade tumor that is best treated with resection, radiation therapy, and chemotherapy. On temozolomide treatment concomitant with radiation therapy, one randomized clinical trial showed a 26.5% two-year survival compared to 10.4% in the cohort receiving only radiation (Zhang, et al.). In this case, the patients tumor was submitted to Tempus for molecular testing to identify mutations that allow enrollment in appropriate clinical trials. Given the support in the medical literature and National Comprehensive Cancer Network (NCCN) guidelines, the Tempus Gene Panel 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 Tempus Gene Panel 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 reviewer 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. This patient does not meet the criteria for being at high risk for developing breast cancer, which is defined as having a 20-25% likelihood of developing the disease. Per the records, she has not had BRCA testing, and the occurrence of breast malignancy in aunts and a cousin does not constitute a greater than 20-25% risk of breast cancer.  Further, her prior mammograms have not detected any abnormalities suggestive of tumor. MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. In some studies, the specificity of breast MRI has been reported to be as low as 37%. In other words, it is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor, but that a follow-up MRI is recommended. Additionally, there are cases where an MRI has not detected a breast cancer. This patient has had consistently stable mammograms, which is probably the best indication that she does not have tumor. The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses. There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  In this particular patient, while it is conceivable that the implant rupture occurred at the time of the mammogram, this is generally a rare occurrence. It is often difficult to distinguish an acute rupture from a chronic pre-existing rupture, and there is no indication on the prior mammogram reports that there were any acute symptoms or comments regarding issues during the procedures. Considering the normal prior mammograms, and the lack of any signs or symptoms of malignancy, a routine mammogram is appropriate in this patients case. All told, the requested bilateral breast MRI is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 diagnostic 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone-acetaminophen 5-325 mg tablets. Findings: Per the Centers for Disease Control and Prevention (CDC), Opioids should be used only when benefits for pain and function are expected to outweigh risks. The CDC recommends that prior to starting opioids, providers should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. The records provided for review document that this patient presents with postsurgical pain following shoulder replacement surgery in January 2022. The provider noted that the patient was on a low dose of hydrocodone-acetaminophen following the surgical procedure. The patient is reported to be participating in a medication monitoring program with his pain management groups with urine drug testing and controlled substance utilization report review. The available records support that the patient is participating in all of the opioid safety and monitoring procedures for opioid analgesic therapy consistent with the current CDC guidelines. Therefore, the requested hydrocodone-acetaminophen 5-325 mg tablets are medically necessary for treatment of this patient. 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 physical medicine and rehabilitation with subspecialty 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: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested for inpatient mental health services for treatment of her severe panic attacks and agoraphobia.    Findings:  The physician reviewer found that the severity of her multiple symptoms were such that it would have been very difficult for the patient to have left the house on a daily basis to attend a partial hospitalization program or to effectively engage in outpatient treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram for evaluation of his medical condition.  Findings: Two physician reviewers found that if coronary ischemia is suspected then some form of stress testing is considered standard of care and most appropriate accepted practice in the medical community (Hendel et al). Coronary CT angiography defines coronary anatomy only, and does not assess the functional significance of any potential stenosis identified. Moreover, Miller and colleagues found that coronary CT angiography is less accurate compared to conventional angiography and may miss small branch vessel stenosis that could be identified on stress testing which may be responsible for the patient's symptoms. Finally, if an assessment of coronary anatomy is thought to be warranted, then conventional coronary angiography is preferred not only because of its improved accuracy but also because of the ability to intervene with coronary revascularization during the same procedure. For these reasons, the diagnostic procedure at issue was not likely to be more beneficial for the evaluation of this patients medical condition than any available standard modality.  Final Result: Two reviewers determined that the procedure 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 19-year-old male enrollee has requested Arthrotec for the treatment of his Raynauds phenomenon, erosive esophagitis and cystic fibrosis. Findings:  The physician reviewer found that Arthrotec is a combination of diclofenac and misoprostol. From the records provided for review, it appears the provider recommended Arthrotec because the patient has erosive esophagitis, is already on a proton pump inhibitor, and may be able to tolerate the combination of diclofenac and misoprostol with a lower risk of gastrointestinal side effects when compared to a conventional, non-selective NSAID. In lieu of Arthrotec, the Health Plan recommends a generic NSAID in combination with misoprostol. The Health Plans formulary appears to include the NSAID diclofenac. Therefore, the alternative proposed by the Health Plan would seemingly allow the patient to take generic diclofenac plus generic misoprostol which are the active ingredients in Arthrotec. As such, a trial of the combination of generic diclofenac and misoprostol would be the next appropriate step for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for carotid artery surgery on both sides. Based on the documentation provided for review and current peer-reviewed medical literature, the requested carotid artery surgery is medically necessary for treatment of this patient. Researchers noted that, Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, the authors concluded that carotid revascularization was associated with improved health outcomes at five-year follow-up. This patients carotid duplex examination reported 50-70% stenosis, and an earlier study showed more severe disease including 90% on left side. In addition, the patients complaints of swelling and redness in the right groin surgical site also require thorough consideration and possible treatment. Overall, the documentation supports an indication for peripheral artery surgery and bilateral carotid endarterectomy. For these reasons, the requested carotid artery surgery on both sides is medically necessary for 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 general surgery with subspecialty certification in vascular 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an external ambulatory infusion pump for insulin with accessories (E0784, A4230, and A4232). Findings:  The physician reviewer found that Continuous glucose monitoring systems enable patients to effectively control and adjust their insulin therapy. Continuous glucose monitoring systems have been found effective in lowering hemoglobin A1c (HbA1c) significantly in adults with type 1 diabetes. In a comparison of the Dexcom G4 Platinum and the Medtronic Paradigm Veo Enlite system, the two most widely used continuous glucose monitoring systems, Kropff and colleagues found the Enlite system was noticeably less accurate than the Dexcom G4 sensor. In this case, the patient has type 1 diabetes and reports problems with the accuracy and reliability of his current continuous glucose monitoring system. Therefore, an external ambulatory infusion pump for insulin with accessories (E0784, A4230, and A4232) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 endocrinology, diabetes and metabolism 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: The patient has requested authorization and coverage for a Monovisc injection to the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs) and several months of physical therapy without benefit. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Monovisc injection to the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her right breast pain.  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Despite the lack of long term studies proving increased survival rates when digital breast tomosynthesis has been added to the usual films of screening mammography, the technique has gained wide support among providers due to an associated decrease in callbacks and increased detection of small cancers. Thus, the addition of breast tomosynthesis was likely of more beneficial to the patient than digital mammography without tomosynthesis.  Final Result: Three reviewers determined that the diagnostic procedure 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: 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: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a Rifton Hi/Lo activity chair. Stewart and colleagues report that modifiable risks for scald injury in children under five years of age include keeping hot objects in the kitchen out of reach of children. Jain and colleagues report that children with autism spectrum disorder (ASD) have more injuries than children without ASD, noting that the injury risk among children with ASD may be driven by co-occurring conditions, including visual impairment, and recommend injury prevention interventions. Choking in individuals with intellectual disability is common and a significant cause of death, with Landes and colleagues reporting in a review of death certificates of adults with intellectual disability in the United States that up to 4.8% of deaths were due to choking and aspiration. Guthrie and Stansfield note that caregivers involved in choking incidents report significant distress and anxiety. In this case, the patient has diagnoses of intellectual disability, ASD, and Cohen syndrome. The patient has visual impairment due to retinitis pigmentosa. The patient has frequent stereotypic behaviors, with violent backwards and forwards rocking when placed in a highchair for feeding. The patient is at high risk for injury, having already sustained bruising to the back and abdomen, and is also at risk of choking during these rocking stereotypies. The patient can propel the current highchair across the kitchen floor and is at risk of scald injury if a pan is knocked off the stove. Given that the requested equipment will adequately restrain the patient during feeding and ensure safety by protecting the patient from injury due to falls, choking, and scalding, the requested equipment is medically indicated. Therefore, a Rifton Hi/Lo activity chair is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that the patient had a remote history of stroke and remote history of left lower extremity fractures. He had been hospitalized with aspiration pneumonia and enterocolitis. He had a limited prior level of function. The patient required oversight of his medical conditions and medication management. There were skilled therapy needs in terms of progressing his mobility and ability to perform essential activities of daily living such as bed mobility without assistance. However, he had received SNF level care for approximately six weeks and his medical conditions were stable. In addition, there were no complex wound care needs. Based on the patients progress, there was little expectation that achieving further gains would impact the burden of care at discharge. Daily skilled services were not medically necessary and the patients condition would not be expected to have deteriorated with services provided on a less than daily basis. The patient had reached a functional plateau consistent his current neurological status and co-morbid medical conditions. The patient was receiving care that could have been provided by his non skilled caregivers with periodic skilled oversight and modification of the care plan if needed. Given these findings, the SNF services provided were 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 physical medicine and rehabilitation 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for double mastectomy with masculinization reconstruction.The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that chest surgery may be carried out earlier than age 18, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. WPATH Standards of Care state, however, that different approaches may be more suitable, depending on an adolescent's specific clinical situation and their goals for gender identity expression. The WPATH reference to one year on testosterone is not an absolute requirement, but is dependent on an adolescent's specific clinical situation. Since the publication of WPATH Standards of Care Version 7, there has been substantial experience by clinicians in the provision of chest surgery for transmasculine youth. Researchers conducted a cohort study that demonstrated the efficacy of chest surgery in relieving distress in transmasculine youth. The study concluded that chest dysphoria was high among presurgical transmasculine youth, and that surgical intervention positively affected both minors and young adults. The study concluded that transmasculine minors should be referred for chest surgery based on individual need rather than chronological age.In this case, the patient has a documented history of gender dysphoria, he has been on puberty blockers for eight months, and he has been documented to have severe distress due to chest dysphoria. In this specific clinical situation, the severity of the patients distress from chest dysphoria supports chest surgery at this time. Under these circumstances, the requested double mastectomy with masculinization reconstruction is medically necessary to treat 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 reviewer is board certified in 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.