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

A 33-year-old female has requested coverage for a past bilateral breast MRI for evaluation performed due to her family history of breast cancer.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the diagnostic procedure at issue.  The current medical evidence does not support a bilateral breast MRI in this clinical setting.  The patient has had no prior biopsies showing atypical ductal hyperplasia or any other lesion known to increase the risk of breast cancer.  She has a history of thyroid cancer, but there is no documentation of external beam radiation therapy to the sternum or chest.  There is no known first-degree relative with breast cancer, and she has not had a prior mammogram.  This patient has no strong predilection for breast cancer based upon family or personal history.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee requested a 24-hour ketamine infusion for five days in an acute hospital setting with periodic outpatient booster for medical treatment of her complex regional pain syndrome.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment options.  There is a paucity of medical literature and double-blind, placebo-controlled studies demonstrating the safety and effectiveness of the requested services.  Most studies call for larger randomized controlled trials and longer follow-up. Additionally, the patients chronic pain condition does not appear to be characteristic of complex regional pain syndrome requiring ketamine infusion.  All told, the requested 24-hour ketamine infusion for five days in an acute hospital setting with periodic outpatient booster infusions is not likely to be more efficacious than other available alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing for frontotemporal dementia for evaluation of the enrollee, who has a family history of frontotemporal dementia. Findings:  The physician reviewer found that the physician reviewer found there is a lack of support for the requested services in this patients case. Genetic testing can detect various mutations associated with familial frontotemporal dementia. However, there is a lack of therapeutic implications relative to the results of the requested testing. The diagnosis remains a clinical one, with treatment generally directed at behavioral issues associated with the disease regardless of the genetic testing results. Accordingly, the requested genetic testing is not likely to confer benefit to the patient clinically. Therefore, genetic testing for frontotemporal dementia is not likely to be superior over other methods of evaluating this patient. Final Result: Two of three reviewers determined that the requested services are 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 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 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 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 male enrollee requested feeding therapy paired with behavioral therapy for medical treatment of the enrollees oral aversion.  Findings:  The physician reviewer found that this patient has severe oral aversion and feeding anxiety, and has failed monotherapy with a speech therapist trained in pediatric feeding disorders. Because of the severity of his anxiety and his extremely limited diet, he requires a team approach to adequately address all facets of his disordered eating.  It is the standard of care to provide such a multidisciplinary approach, and it is thus medically necessary for this patient to receive feeding therapy paired with behavioral therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested for a Positron Emission Tomography (PET) study for evaluation of her ovarian cancer.   Findings:  Three physician reviewers found that a review of the literature indicates that PET scan is an appropriate diagnostic test for evaluation of patients with ovarian cancer. The number of patients in the studies ranged from 8 to 132. In some of the studies, the patients had rising CA-125. All the articles supported the use of PET or PET/CT to identify and help characterize recurrent ovarian cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza.Findings: Victoza (liraglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist that, in addition to stimulating insulin release and inhibiting glucagon secretion, slows gastric emptying and increases satiety after eating. Liraglutide has been demonstrated to reduce food intake, promote weight loss, and improve indices of metabolic function in both animal and human studies. A study states that the primary mechanisms associated with these effects are proposed to be due to actions of GLP-1 on peripheral (vagal) and central pathways that affect food intake and metabolism via hindbrain and hypothalamic activation, as well as those brain areas associated with motivation and reward processes. While obesity may not be a direct cause of PCOS, obesity does exacerbate many aspects of the phenotype, according to another study. While lifestyle intervention is first-line in the management of PCOS to both prevent weight gain and induce weight loss, another study states that medications such as GLP-1 agonists have been used to help promote weight loss and thereby prevent potential long-term complications in this patient population. In this case, the patient has had success with Victoza. Additionally, the medical literature supports the use of GLP-1 antagonists to help promote weight loss in patients with PCOS. Therefore, Victoza is medically necessary for the treatment of the patients medical condition.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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test provided for evaluation of the enrollee who has a family history of von Hippel-Lindau syndrome. Findings:  The 3 physician reviewers found that there is sufficient support in the medical literature for the services at issue in this clinical setting. VHL syndrome is inherited in an autosomal dominant manner. Approximately 80% of individuals with VHL syndrome have an affected parent and about 20% have VHL syndrome as the result of a de novo pathogenic variant. The offspring of an individual with VHL syndrome are at a 50% risk of inheriting the VHL pathogenic variant. In this patients case, little is known regarding the VHL status of the patients father, making it difficult to quantify the patients risk of being affected with VHL.  However, given the family history of VHL, a history of hypertension and hypercholesterolemia in the patients father (VHL status not reported) and recurrent abdominal pain in the patient, VHL syndrome is a diagnostic concern.  While this diagnosis seems unlikely given the lack of accompanying features (none reported), the diagnosis of VHL is established by genetic testing even when clinical and radiographic features are inconclusive.  Testing for VHL should begin with sequence analysis of VHL, followed by gene-targeted deletion/duplication analysis, both of which were conducted in this case. The use of these technologies (sequencing and deletion/duplication testing) represents the standard of care and is not investigational. All told, the gene test provided was likely to have been more effective than any available methods for the evaluation of this patient. Final Result: The 3 reviewers determined that the  services at issue were likely to have been 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 medical genetics and genomics 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 medical genetics and genomics 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 medical genetics and genomics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a MyoPro Motion G orthotic device. There is a lack of evidence in current medical literature supporting the use of the requested device following a cerebral event, such as stroke, in assisting a patient with  regaining neurological or muscular strength or function, such as the innate ability to use the arm for functional tasks when the orthosis is removed. The available medical literature regarding the potential of the device is limited and does not establish proven health outcomes, such as reduction in the incidence of overuse injury of the sound, unaffected limb. Recent and current literature regarding the potential of the device to improve strength or function is limited to anecdotal literature and small trials, including industry-supported trials, with larger trials either in progress or planned.  Researchers note that rehabilitation efforts to reduce shoulder subluxation in post-stroke hemiparesis should aim to support and suspend the shoulder and arm weight. Due to its weight, the requested device may cause the shoulder to sublux and result in greater instability for a patient with hemiparetic gait by displacing the center of gravity. In this case, the patient is noted to have chronic weakness of the arm following a stroke in 2013. In this clinical setting, the weight of the requested device would make it difficult for the patient to position his upper extremity for purposeful use of the device. The requested device is not proven to enhance or replace the role of conventional orthoses and is not expected to provide clinically or functionally significant marginal benefits over conventional orthotic therapy. Therefore, a MyoPro Motion G orthotic device is not likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MyoPro Motion G orthotic device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is 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 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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 20-year-old male enrollee has requested Ilaris injections for treatment of his juvenile rheumatoid arthritis.  Findings:  Two physician reviewers found that this patient has already failed standard therapy, and still has active disease. At this point, the treatment options involve medications which have been developed for the management of problems other than juvenile rheumatoid arthritis.  The use of Ilaris has gradually extended into other disease conditions, including systemic juvenile idiopathic arthritis. Ilaris has been reported to be quite successful in controlling disease manifestations in such patients, and its use represents an appropriate recommendation for patients who have failed standard therapy. Since the number of patients with systemic juvenile idiopathic arthritis who have failed standard therapy is fairly small, there are no randomized controlled trials of its use for this condition. However, case reports have described benefit. In this patients case, Ilaris injections are likely to be the most efficacious treatment alternative.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old male enrollee has requested partial hospitalization program (PHP) services for treatment of his bipolar disorder and alcohol dependence.  Findings:  The physician reviewer found that according to the documentation, the patient was not faring well on his own and had a significant level of depression and anxiety. No doubt, this was worsened by his drinking, though the cyclic relationship between the problems, with one issue compounding the other, is very complex. To that extent, admission to a PHP program was eminently reasonable.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female who walks with an assistive device. She indicates she experiences flares in her condition, which prevent her from walking. There is no evidence the patient is currently experiencing a flare, nor is it known how frequently these occur or how long they last. The medical documentation provided regarding the patients gait indicates the patient walks slowly while ascending stairs and walks independently for short distances. The patient has requested authorization and coverage for a power-operated vehicle (POV). :The Health Plans denial should be upheld. The submitted information does not demonstrate the patient is non-ambulatory. The patient has a manual wheelchair that she is able to use. Thus, the provided documentation does not demonstrate the patient is precluded from operating a manual wheelchair. As such, the medical necessity of a POV has not been established. Therefore, I have determined the requested POV is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested for Rituxan (rituximab) therapy for treatment of her cryoglobulinemia.   Findings:  The physician reviewer found that mixed cryoglobulinemia is an immune complex mediated disease involving small to medium vessel vasculitis. It is associated with HCV in many instances. This disease can affect vital organs including the kidney, liver and heart. Early treatment often involves a combination of antiviral medication, interferon-alpha and ribavirin. Plasmapheresis, steroids or immunosuppression are utilized at later stages.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested the use of a low load prolonged static ankle stretching device (DynaSplint) for treatment of her Guillain-Barre syndrome. Findings:  Two physician reviewers found that there are some published case reports and case series in the medical literature related to the use of low-load prolonged-duration dynamic orthoses (such as the DynaSplint) for various joints. There is, however, no high-grade data in the published peer-reviewed medical literature supporting the efficacy of the DynaSplint for ankle contractures or spasticity. Low-load prolonged-duration dynamic orthoses such as the Dynasplint remain unproven for patients with reduced range of motion at the ankles due to Guillain-Barre syndrome or other neurological conditions.  There is no compelling data establishing that the device is as effective or more effective than a rigorous exercise program combined with appropriate analgesics and palliative modalities.  Overall, the DynaSplint system is not likely to be as efficacious for treatment of the patients condition, as it is not proven to be effective for this condition. Moreover, the patients ankle range of motion did not improve significantly with DynaSplint therapy. All told, there is inadequate evidence supporting the use of the DynaSplint device in this setting.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Synvisc-One injection in the left knee. The patients pertinent diagnoses are degenerative joint disease of the knee, synovitis, meniscus tear, primary osteoarthritis of the left knee, and chondromalacia. The patient has been treated in the past with rest, several non-steroidal anti-inflammatory drugs, cortisone injections, braces, physical therapy and lifestyle changes; with minimal improvements in the underlying degenerative joint disease. With established efficacy of hyaluronic acid injections, and failure of other conservative treatments, including oral medication and corticosteroid injections, a repeated Synvisc-One injection is appropriate and medically necessary for this patients degenerative joint disease of the knee.  Literature reports intraarticular hyaluronic acid improved pain in five studies, or function in four studies, when compared to placebo. In sum, there is support in the literature for the use of a repeat injection for the treatment of this patients condition.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with non-specific symptoms. She was unresponsive to L-DOPA/arginine stimulation testing and had transient symptomatic response to Mestinon. Her current status is at the baseline level of malaise or worse. The patient has requested authorization and coverage for growth hormone therapy. The Health Plan has denied this request on the basis that growth hormone therapy is not medically necessary.The submitted information lacks evidence of definitive testing for growth hormone therapy. The L-DOPA/arginine stimulation test was remarkably unresponsive. In addition, the patients symptoms are non-specific. Furthermore, the patients low estrogen and high FSH are consistent with menopause and rule out global hypopituitarism. The patients transient response to Mestinon is non-specific. Given these findings, a gold standard test of growth hormone response is indicated (e.g., insulin hypoglycemia or GHRH/arginine stimulation test). Once these results are available, the patients request for growth hormone therapy should be re-evaluated. Based upon the information provided, I have determined the requested therapy is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. The patient should receive insulin hypoglycemia or GHRH/arginine stimulation testing; her request for growth hormone therapy should be reconsidered based upon the test results.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested partial hospitalization program (PHP) level of care services and intensive outpatient program (IOP) level of care services for medical treatment of her eating disorder.   Findings:  The physician reviewer found that applying the American Psychiatric Association (APA) guidelines, the patients significant comorbidities including PTSD and depression, she remained at elevated risk for undue morbidity and admission to a higher level of care in the absence of initial PHP services. In sum, the PHP services were initially medically necessary for treatment of this patients medical condition, while later  PHP services and IOP services forward were not and are not medically necessary. I have determined that a portion of the services were medically necessary for treatment of the patients medical condition.