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

A 36-year-old female enrollee has requested  for laser therapyfor treatment of her pervasive periungual warts. Findings:  Three physician reviewers found that the clinical management of verruca vulgaris is often challenging, and an ideal treatment does not currently exist. While no treatment is universally effective, some patients respond better to one treatment than another. No guidelines have been published as to which patient will respond best to which treatment. Given that there are no specific antiviral therapies to cure HPV infection, destructive methods such as pulse dye laser are sometimes employed.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Tafinlar and Mekinist for treatment of the enrollees adenocarcinoma of the mullerian origin. Findings: The physician reviewer found that there is a lack of support for the requested medication regimen in this clinical setting.  Patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials.  This may be particularly relevant for very rare cancers where even phase II studies may be not be effectively conducted due to poor accrual.  Recently, it has become important to identify mutations that may be amenable to targeted therapy.  This patients tumor had mutational profiling which revealed a gain of function BRAF mutation, v600e, which has been described in melanoma, colon cancer, lung cancer, and hairy cell leukemia, among others.  Mekinist is an inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF.  The MEK kinases are within the same pathway as RAS and BRAF.  Thus, it is mechanistically appealing to apply Mekinist to tumors with constitutive RAS signaling, such as the tumor under discussion.  However, there is not sufficient experience of this combination in ovarian cancer compared to colon cancer.  All told, Tafinlar and Mekinist are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 medical oncology 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 authorization and coverage for intraoperative radiotherapy (IORT) (CPT 77424 and 77469). Current guidelines endorse the use of IORT in the treatment of breast cancer (Gradishar, et al.). Based on the available documentation, this patient meets all of the criteria for the use of IORT in patients with invasive ductal cancer. Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT (Correa, et al.). The benefits of undergoing IORT include fewer treatment visits and treatment of a smaller volume than with standard modalities. Furthermore, IORT would decrease toxicities for this patient, who is undergoing radiation for a second time to an adjacent field. Therefore, the requested IORT (CPT 77424 and 77469) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IORT (CPT 77424 and 77469) 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old male enrollee has requested authorization and coverage for transforaminal lumbar interbody fusion (TLIF) at L4-5 approach to the disc(s) for total facetectomy, hemilaminectomy, foraminotomy with discectomy, interbody arthrodesis, restoration of height, reduction of spinal listhesis and placement of a prosthetic interbody cage.  Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain.  In the case of this patient, there is a lack of evidence of lumbar spinal deformity, instability or disc re-herniation. Thus, the patient does not meet the above mentioned indications for spinal fusion. Further, the American Pain Society has also developed evidence-based recommendations on the use of interventional surgeries for low back pain of any duration, which states that surgical benefits are often only moderate and appear to decrease over time (Chou, et al.). Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, as well as the lack of evidence that this patient meets clinical indications for surgical fusion, the requested procedure is not medically necessary for treatment of the patients low back pain. The Health Plans denial was appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee requested LINX Reflux Management System procedure for medical treatment of her gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that the request for LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the study by Salminen and colleagues, Nissen fundoplication as the procedure of choice in surgical management of gastroesophageal reflux disease. In addition, there is a lack of controlled trials comparing the efficacy and safety of LINX to Nissen fundoplication. Although early studies in regards to LINX are encouraging, the studies to date are primarily less than five years. Because of the lack of controlled data and long-term studies, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intravenous immune globulin (IVIG) for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. The treatment of specific antibody deficiency with replacement immunoglobulin, although U.S. Food and Drug Administration approved, is controversial. Although there have been recurrent infections, there is no supporting documentation, such as chest CT, sinus CT or antibiotic log to confirm recurrent infections. The patient has not been vaccinated with the conjugate pneumococcal vaccines. There also is no documentation of a trial of prophylactic antibiotics. In sum, the records do not support a diagnosis of CVID.  Therefore, the use of IVIG is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested services 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 internal medicine, allergy and immunology and 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

A 49-year-old female enrollee is requesting authorization for an Oncotype DX tumor assay for evaluation of breast cancer.Reviewers' Findings:  The three reviewing physicians found there is good literature support for the assay's reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. The assay has become very important as it is particularly in this group of breast cancer patients that it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, this assay has been rapidly adopted by many oncologists as part of their standard evaluation of such patients, and Medicare has approved its use.
Appeal type: Experimental/Investigational
Decision: Overturned

A forty-eight year-old female with chronic headaches diagnosed as migraines and chronic cervical pain is requesting for continued authorization of Botox therapy.Reviewers Findings:Two of the reviewing physicians found that Botox therapy would be beneficial for treatment of the patients medical condition.  The Third physician found that Botox therapy is not likely to be more beneficial for treatment of the patients medical condition.  The physicians found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether the allergen-specific testing,  that was provided was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy. The patient presented for complaints of ongoing and intermittent abdominal soreness, diarrhea, bloating, and back pain. She also reported anxiety, closing throat, and palpitations. She described these symptoms as worsening with eating. The symptoms first occurred approximately two months prior after starting naturopathic hormone treatment.Findings:  Three physician reviewers found that the medical records fail to demonstrate allergic immunoglobulin E (IgE) type reactions to foods or a causal association with a specific food type.  The two major recent practice parameters posted by the National Institute of Allergy and Infectious Diseases (NIAID) and American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology (AAAAI/ACAAI) Joint Task Force see immunoglobulin G (IgG) food testing as non-validated and do not recommend this form of testing. Blood tests for food allergies demonstrate positive test results in normal, non-food allergic people. As such, allergen-specific testing, that was provided was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested test is 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 allergy and immunology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gelsyn-3 injections in 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 a history of chronic right knee pain that has worsened due to her weight gain over the past year. Due to the mild nature of the osteoarthritis, the patient is not a candidate for joint replacement. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Gelsyn-3 injections in the right knee 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) (CPT codes 72146 - MRI spinal canal thoracic without contrast material x 1, and 72148 - MRI spinal canal lumbar without contrast material x 1).The American College of Radiologists (ACR) Appropriateness Criteria for lumbar imaging generally recommend MRI without contrast for patients with subacute or chronic low back pain with or without radiculopathy and surgery or intervention candidates with persistent or progressive symptoms during or following six weeks of conservative management. ACR guidelines recommend MRI only if severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition are present, or if the patient is a candidate for invasive interventions. Immediate imaging is recommended for patients with major risk factors for cancer, spinal infection, cauda equina syndrome, or severe or progressive neurologic deficits. In this case, the patient is being treated for scoliosis and back pain. He noted that the back pain is worsening. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Detailed documentation is not evident regarding severe and/or progressive neurological abnormalities. Furthermore, there are no objective findings provided corroborating the noted scoliosis. No x-rays were noted or provided of the thoracic and lumbar spine. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested magnetic resonance imaging (MRI) (CPT 72146- MRI spinal canal thoracic without contrast material x1; 72148- MRI spinal canal lumbar without contrast material x1) is not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services 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 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: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested neuropsychological testing for evaluation of the enrollees hyperkinetic syndrome.  Findings:  The physician reviewer found that specific learning disability and attention-deficit hyperactivity disorder (ADHD) are two distinct neurobehavioral developmental disorders that commonly occur in children. About 20% of children with specific learning disability have associated ADHD and vice versa. Researchers are divided at to whether each of these disorders has an independent etiology or the frequent co-occurrence is the result of a generalized atypical brain development. In either event, both specific learning disability and ADHD are known to impair educational achievement and social functioning. In addition, patients with specific learning disability and ADHD tend to have more severe learning and attention problems than those with specific learning disability alone. Thus, a thorough evaluation for ADHD should include assessment for associated co-morbid conditions. For this reason, the neuropsychological testing and evaluation performed were medically necessary to assess this patients possible co-morbid conditions that may impact his future development. In fact the diagnostic testing indicated the patient is at risk for specific learning disorder, which will guide in the management of his deficits.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast ultrasounds.Medical literature supports breast ultrasound as an augmentation to routine mammography. When a lump or suspicious abnormality is discovered on routine mammography, a targeted breast sonogram is the next step prior to biopsy. The issue, however, is that automated whole breast sonography is performed as an adjunct to mammography, not as a replacement. Berg and colleagues have demonstrated an increased detection rate of occult breast cancer in a screening population when sonography is added to routine mammography. Whether one uses an automated mechanism or simply scans the entire breast, the issue is still whether breast sonography is adequate as a solitary screening test for breast cancer. Kaplan states that automated breast ultrasonography is a developing technology that has been recently approved by the U.S. Food and Drug Administration for use in screening for breast cancer as an adjunct to mammography. There are limitations for any type of sonography in evaluating breasts. Specifically, automated whole breast ultrasounds cannot diagnose microcalcifications, and is marginal in evaluating the deeper portions of the breast. In this case, the referring practitioner has requested only breast sonography as a screening procedure. However, whole breast sonography is not a replacement for mammography and should be used in addition to a mammography. Therefore, the requested bilateral breast ultrasounds are not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the 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: Upheld

A 30-year-old female enrollee requested a referral to an ear, nose and throat (ENT) specialist and a referral to a cardiologist for medical treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient has been diagnosed with post-nasal drip, allergic rhinitis, multiple somatic complaints and anxiety.  The neurological examination and cardiovascular examination have been normal.  The patient has not been reported to have any concerning cardiovascular symptoms, and imaging of the brain and partial sinus was normal.  All told, the requested referral to an ear, nose and throat (ENT) specialist and a referral to a cardiologist are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for weight loss surgery involving CPT code 43644 (laparoscopy, surgical, gastric restrictive procedure with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm of less), CPT code 43846 (Gastric restrictive procedure, with gastric bypass, for morbid obesity, with short limb (less than 100 cm) Roux-en-Y gastroenterostomy and two days of inpatient acute hospitalization. The health plan has denied this request as not medically necessary. A review of the records indicates this enrollee was evaluated by her surgeon for gastric bypass weight loss surgery. She previously weighed 215 pounds but had reduced her weight to 193 pounds using a professionally monitored weight loss program with exercise. Her co-morbidities, potentially associated with morbid obesity, are obstructive sleep apnea (OSA), gastroesophageal reflux disease, osteoarthritis of the knees and lumbar disc disease. Her body mass index (BMI) had been equal or greater than 35. She also had a psychiatric evaluation done and successfully completed a professionally monitored weight loss program. The enrollee wanted to proceed with a Roux-en-Y gastric bypass weight loss surgery proposed by her surgeon. According to the medical literature, a consensus panel indicated that bariatric surgery is appropriate for all patients with a BMI (kg/m2) greater than 40 and for patients with a BMI between 35 to 40 with associated co-morbid conditions. Bariatric/metabolic surgery is currently the only effective long-term treatment for morbid obesity and obesity-related diseases, such as diabetes, heart disease, hypertension, obstructive sleep apnea and dyslipidemia. Bariatric/metabolic surgery has also been shown to significantly reduce the incidence of diabetes and cancer and prolong life when compared to non-surgical therapies. The records show this patient has life threatening comorbidities, including obstructive sleep apnea. The patient has shown compliance with the required weight loss and exercise program. 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 General 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.