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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (measurement of antibody to vedolizumab). Findings:  Three physician reviewers found that the current medical evidence does not definitively demonstrate that the services at issue are beneficial for health outcomes in the management of Crohns disease. The published studies including the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions regarding cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-Entyvio antibodies. Additionally, the antibodies can be transient. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with Crohns disease compared with conventional management. For these reasons, laboratory testing (measurement of antibody to vedolizumab) was not likely to have been more effective than other methods of evaluating this patient.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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 reimbursement for FoundationOne testing. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, FoundationOne testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of FoundationOne in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the FoundationOne test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and are 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 is diagnosed with Graves disease. She reportedly tried and failed methimazole at a low dose and therefore is currently on a methimazole compounded preparation at a dose of 1.25 mg every other day. Laboratory results in September 2018 showed a thyroid stimulating hormone (TSH) level of 2.08, a free T4 level of 1.2, and a free T3 level of 2.3. Laboratory results in December 2018 revealed a TSH level of 2.71, a free T4 level of 1.17, and a free T3 level of 2.2. The patients body mass index is 26.22. The patient has requested coverage for methimazole compound. The Health Plan denied the request and reported the medication is not medically necessary for the treatment of this patient. At issue in this case is whether methimazole compound is medically necessary for the treatment of the patients medical condition. The records provided for review document that this patient was unable to tolerate methimazole at a low dose, and is currently on a methimazole compound at a dose of 1.25 mg every other day. Periodic clinical and biochemical evaluation of thyroid status in patients taking antithyroid drugs (ATDs) is crucial for proper adjustment of mediations. An assessment of serum free T4 and total T3 should be obtained two to six weeks after initiation of therapy, depending on the severity of the thyrotoxicosis, and the dose of medication should be adjusted accordingly. Once euthyroid levels are achieved with the minimal dose of medication, clinical and laboratory evaluation can be undertaken at intervals of two to three months. This patient requires methimazole at much smaller dose than is available in the existing U.S. Food and Drug Administration (FDA) approved tablet forms of 5 mg and 10 mg. At the reduced dose of 1.25 mg every other day, the patient is clinically and biochemically euthyroid. Therefore, the requested methimazole compound is medically necessary for treatment of this patients Graves disease.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two rteviewers 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for oral immunotherapy for treatment of the patients medical condition than any available standard therapy. Findings:  The physician reviewer found that oral immunotherapy has not been recommended by the guidelines due to the lack of data that the therapeutic benefits outweigh the risk of treatment. Oral immunotherapy may promote desensitization to peanut protein in children and adolescents with peanut allergy. However, oral immunotherapy has been associated with increased risk of adverse reactions. Oral immunotherapy with rush phase or build-up phase may improve peanut tolerance but may induce moderate-to-severe allergic response.  Oral immunotherapy is associated with higher rate of systemic adverse events compared with other forms of immunotherapy as well as a minor risk of eosinophilic esophagitis. For these reasons, oral immunotherapy is not considered within the standard of care. Accordingly, the requested oral amino therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 is board certified in allergy and immunology and pediatrics and is actively practicing. Physician reviewers 2 is board certified in allergy and immunology with expertise in pediatric allergy and immunology and is actively practicing. Physician reviewers 3 is 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: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested an MRI, including CPT code 73220 for evaluation of her left arm injury. Findings:  The physician reviewer found that this patient has a diagnosis of left ulnar neuropathy. With this diagnosis, there is concern of entrapment of the ulnar nerve. MRI is an accepted imaging study for the evaluation of the ulnar nerve. MRI can determine if the ulnar nerve is inflamed, entrapped by a bone spur or surrounded by scar tissue from prior trauma.  The American College of Radiology guidelines advocate for MRI of the elbow to evaluate for ulnar neuropathy.  Vucic and colleagues noted that MRI of the ulnar nerve should be used in patients with clinical features of ulnar neuropathy.  Andreisek and colleagues stated that MRI may help establish the cause of the condition and provide information crucial for conservative management or surgical planning for patients with a diagnosis of peripheral neuropathy. Hochman and Zilberfarb noted that imaging can have an important role in defining the site and etiology of nerve compression. Most entrapment abnormalities of the ulnar nerve are located within the elbow, although abnormalities within the forearm and wrist can also lead to ulnar neuropathy.  MRI studies can also be used for surgical planning.  MRI was medically indicated for this patients evaluation and treatment planning.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the inpatient hospitalization services provided from 8/30/17 through 9/1/17 for treatment of the enrollees acute on chronic cholecystitis. Findings:  The physician reviewer found that Acute cholecystitis can be managed with cholecystectomy as a day surgery procedure, or with a short observation stay. The records provided for review document that this patient did not have protracted hypotension, tachycardia, or other signs of severe volume depletion or sepsis. Imaging performed just after presentation was not consistent with pathology such as biliary obstruction, gallbladder perforation, pancreatitis, or complications of gallstone disease. Additionally, the patient did not have acute cholangitis, active gastrointestinal bleeding, gastrointestinal perforation, peritonitis, abscess, sepsis, or other gallbladder or biliary complications warranting inpatient level of care (Tang, et al; Wilkins, et al; Macaluso and McNamara). She was appropriately evaluated for gallbladder disease, and her disease was fully addressed with laparoscopic cholecystectomy, which could have been performed without the inpatient level of care. For these reasons, the inpatient hospitalization services provided from 8/30/17 through 9/1/17 were not medically necessary for the treatment of the patients acute on chronic cholecystitis. Final Result: The reviewer determined that the services at issue were 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested posterior tibial nerve stimulation for treatment of her overactive bladder.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of long-term follow-up data in the peer-reviewed literature to validate the sustained benefit of nerve stimulation in the treatment of lower urinary symptoms. The medical literature in regards to PTNS in this clinical setting remains controversial. Therefore the requested services are not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Two of the three physician reviewers found that the medical evidence supports cystic fibrosis carrier screening for all women of childbearing age. With regards to fragile X testing, according to the American College of Medical Genetics, if a woman has ovarian failure before the age of 40, DNA testing for pre-mutation size alleles should be considered as part of the infertility evaluation and prior to in vitro fertilization. This patient required in vitro fertilization to conceive. Given the history of fertility issues, fragile X testing was appropriate. With regards to spinal muscular atrophy, carrier testing should be offered to all couples regardless of race or ethnicity. In the absence of a significant family history, carrier screening of more than 200 conditions (in addition to conditions described above) was not indicated. The value of this screening is uncertain and is not standard of care. Thus, fragile X, cystic fibrosis and spinal muscular atrophy testing were standard of care and were likely to be of greater benefit than other methods of evaluating this patient. However, the superior effectiveness of the remaining of the services at issue has not been established.Final Result: The reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in clinical biochemical genetics and are actively practicing. Physician reviewer 3 is board certified in clinical cytogenetics and genomics 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 Otezla for the treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been treated with medications, with reported side effects to these medications. The available medical records do not document or provide objective evidence of ongoing disease activity or progression of disease activity that would necessitate treatment with an escalation of therapy with Otezla.  On the basis of the available medical records and per the peer-reviewed medical literature, Otezla is not medically indicated 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 internal medicine with sub-specialty certification in rheumatology 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 requested authorization and coverage for genetic testing with clinical exome sequencing for evaluation of the enrollees progressive ataxia in legs and hands. Findings:  The 3 physician reviewers found that whole exome sequencing can be helpful in patients with symptoms of an underlying genetic disorder to diagnose them with a specific condition. The use of this method allows the patients providers to provide more effective therapy as well as genetic counseling for family members. This patient is likely to benefit from undergoing whole exome sequencing as she has a longstanding condition and would benefit from determining the cause of her symptoms. Given this support, the requested genetic testing with clinical exome sequencing is 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 requested testing is 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 number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that the National Institutes of Mental Health discovered that among the many methods available for treatment of individuals with autism, ABA has become widely accepted as an effective treatment. Filipek and colleagues indicate that treatment requires a comprehensive multidisciplinary approach that includes speech-language therapists and occupational therapists. Foxx and colleagues note that ABA is a state of the art treatment modality for this medical disorder. ABA utilizes methods derived from scientifically established principles of behavior. Various behavior and analytic methods are employed and individualized for the patients. Whenever possible, treatment should approximate the patients natural environment. ABA therapy is a therapeutic intervention and a health care service and is accepted in the professional standards of practice. The medical records of this patient document the impairments and symptoms that support the need for the requested ABA therapy, speech therapy and occupational therapy. These requested services are medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Fasenra injection. A review of the records indicates this patient has a medical history of eosinophilic asthma, chronic eosinophilic pneumonia, chronic sinusitis, and vocal cord dysfunction. She has respiratory insufficiency that progressed. She has been experiencing shortness of breath, wheezing, and low oxygen saturations despite nebulizer treatments, steroids, and inhalers. Her provider recommended therapy with Benralizumab Fasenra, which could be expected to reduce the steroid dependence and toxicity and likely reduce her need for healthcare use. The patient stated that her saturations of oxygen were in the high 80s despite nebulizer treatments every two hours with ipratropium, and cromolyn, and Xopenex, along with use of prednisone.   She indicates she was given sample Fasenra injections, after which her wheezing resolved and shortness of breath and oxygen saturations improved.  The patient had a diagnosis of eosinophilic asthma and had benefit with use of the medication, as she was able to breathe better.  The medical literature did not indicate that a patient must trial Nucala prior to the use of Fasenra.  Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Pulmonology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.Findings:  The physician reviewer found that