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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fecal analysis laboratory test for gastrointestinal pathogens (CPT 0097U). The Enteric Pathogen Panel is an automated test that is able to identify multiple enteric pathogens in stool during one run via polymerase chain reaction (PCR). When available, the Enteric Pathogen Panel is accepted as standard practice for rapid identification as cause of diarrhea in patients who have symptoms for more than seven days, no history of international travel, and are not immunocompromised. This patients records demonstrate that she met these criteria for testing. The patient was tested for acute diarrhea given her presentation of leukocytosis and fever with more than seven days of symptoms with prior risk factors for Clostridium difficile including antibiotic use. The Enteric Pathogen Panel successfully identified the cause of her illness as Clostridium difficile and she was then successfully treated. In this case, the Enteric Pathogen Panel was the most efficient means to identify the cause of the patients illness, fever, leukocytosis, and diarrhea. Given this support, the fecal analysis laboratory test for gastrointestinal pathogens (CPT 0097U) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the fecal analysis laboratory test for gastrointestinal pathogens (CPT 0097U) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in infectious disease 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 authorization and coverage for implantation of hypoglossal nerve stimulator. In the peer-reviewed medical literature, it is concluded that upper airway stimulation is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA [obstructive sleep apnea] who have failed nasal continuous positive airway pressure. However, this patients trial and failure with continuous positive airway pressure is not well documented in the records provided for review. In addition, the patient has periodic limb movement sleep disorder and insomnia as well as moderate obstructive sleep apnea. According to the current data, these sleep related comorbidities have not been studied in trials for hypoglossal nerve stimulator implantation. For these reasons, the requested hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any standard therapy.One reviewer found that the requested hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in otolaryngology with subspecialty certification in plastic and reconstructive surgery and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology with subspecialty certification in sleep medicine and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar injection for treatment of the enrollees nephrotic syndrome with focal segmental glomerular sclerosis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. According to research Current first-line anti-proteinuric treatments for nephrotic syndrome (NS) do not produce an effective response in all patients and are not tolerated by some patients. Additional effective and tolerable treatment options in NS are strongly needed. The authors examined Acthar gel in patients with varied-etiology NS. The authors concluded that Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. In this case, the patient has failed first-line therapy and is at a high risk for renal replacement therapy due to need proteinuria and reduced renal mass. 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 nephrology 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 48-year-old female enrollee requested a pain management consultation for medical treatment of her neck pain, fibromyalgia, carpal tunnel syndrome, and sciatica. Findings:  The physician reviewer found that based on the available medical records, a pain management consultation is not medically necessary for treatment of this patients medical condition. Overall, there is lack of documentation of the patients response to conservative therapy, which may be appropriately ordered and assessed by the patients primary care physician. Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications. Additionally, the results of the imaging do not demonstrate any pathology requiring a pain management consultation prior to failed conservative therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Afirma Gene Expression Classifier for the evaluation of her medical condition.  Findings:  Three physician reviewers found that the medical evidence supports the services at issue in this patients case.  The genetic testing was a major determining factor in delineating the further course of action to see if a possible surgical procedure was warranted.  There is sufficient literature indicating that this test can be performed to avoid needless surgeries.  Thus, Afirma Gene Expression Classifier was likely to have been superior over other methods of evaluating this patient. Final Result: Three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Treatment-naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Consistent with these findings, the requested Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. Final Result:  Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Urgent Care
Decision: Overturned

The parent of an enrollee has requested reimbursement for MRI-guided stereotactic laser ablation therapy for the treatment Hypothalamic Hamartoma. The patient had a history and thorough work up that included a neurological assessment and magnetic resonance imaging (MRI) of the brain. The patients MRI revealed a hypothalamic mass compatible with Hypothalamic Hamartoma (HH), which is considered a rare condition. The patients clinical history of gelastic seizures lasting long enough to be characterized as status gelasticus is incontrovertible. The patients diagnosis of HH was radiologically confirmed and fit well with the patient's presentation and clinical history. The patient underwent reasonable trials of anti-epilepsy drugs (AEDs) which were instituted without success, raising the specter of medically refractory seizures. While the clinical course and kinetics of disease pathogenesis of HH may be highly variable, the patient clearly had an aggressive presentation and clinical history for HH. Under these circumstances, the absence of immediate medical attention could reasonably have been expected to result in placing the patients health in serious jeopardy, or caused serious impairment to bodily functions and/or serious dysfunction of any bodily organ or part, and the patient therefore had an emergency medical condition. Furthermore, the patient required care, treatment, and surgery to relieve or eliminate the emergency medical condition on the date of service. Accordingly, the services provided were emergency medical services as defined by California law.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology, with special qualification in child 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 parents of a five-year-old male with a serious psychiatric problem are requesting authorization of continued partial hospitalization.Reviewers Findings:  The reviewing physician found that the program the patient is currently attending is medically appropriate and clinically indicated based on the information provided.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested a duodenal switch with biliopancreatic diversion for the treatment of her morbid obesity. Findings:  The physician reviewer found that as bariatric surgery becomes safer and studies are carried out longer term, patients have multiple options in selecting their procedures. Consensus groups, including the National Institutes of Health and the American Society for Metabolic and Bariatric Surgery, recognize three options. These are Roux-en-Y gastric bypass, adjustable gastric banding and duodenal switch with biliopancreatic diversion. Many patients with significant hepatosteatosis cannot undergo Roux-en-Y gastric bypass due to the technical difficulty of a high gastrojejunostomy. In the case of this patient, her BMI is 47, and she requires NSAIDs.  Her hepatic span of 20 cm and relatively short height will make a laparoscopic Roux-en-Y gastric bypass procedure more difficult. As such, duodenal switch with biliopancreatic diversion is medically indicated for this patient and is the most appropriate surgical option.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for scar tissue removal surgery. The patient underwent cosmetic breast augmentation surgery years ago and developed an area of depressed scar that pulls on the underlying tissue when she raises her arm. She reports pain when this occurs. Kumar and Elavarasi stated, Pain is always subjective, and every individual use this word through their previous experience related to the injury. Attachment of a scar to the underlying tissues may result in discomfort. Based on the history of the presence of severe pain, scar tissue removal is medically necessary. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, a depressed scar following breast augmentation surgery is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. The appearance of the patient is normal, and scar revision would result in only minimal improvement in appearance. Therefore, the requested scar tissue removal surgery is not reconstructive in nature for 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism. Findings:  The physician reviewer found that although the treating OT provider has documented functional goals for this patient, the goals are not easily quantifiable. The patient has been receiving occupational therapy on and off for over two years, yet the submitted records provide no documentation demonstrating benefit of the therapy over time. The treating provider has not performed standardized assessments documenting the need for these services. Although the in-network OT evaluation utilized a standard evaluation (the Peabody Developmental Motor Scale (PDMS)), no attempt was made to use a standardized assessment to measure issues with sensory processing, which is a common issue with young patients with autism. All told, the submitted clinical evidence fails to establish a treatment baseline, does not articulate specific functional goals, and does not objectively document the patients progress toward goals. Thus, the medical necessity of the requested services has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for Decision DX UM melanoma assay for evaluation of the enrollees uveal melanoma (UM).Findings:  Two physician reviewers found that Uveal melanomas arise from melanocytes in the uvea, as was the situation in this case. Uveal melanomas tend to present with visual symptoms and are diagnosed upon funduscopic evaluation. The literature reports that local treatment is effective in preventing local recurrence in over 95% of cases, but 50% treated with enucleation developed metastatic disease over a five year follow up period. Clinical factors associated with poor prognosis include large tumor size, involvement of the ciliary body, increased age, and extrascleral extension. DecisionDX UM is a 15 gene panel expression assay which classifies genes based on a calculation from the gene expression and comparison with a training set of known outcomes. Multiple studies have been performed to validate its use, and these small studies indicate that the score generated permits clinicians to individualize the patients surveillance plan. Although DecisionDX may provide an additional risk assessment tool, the current treatment and surveillance options (post-surgical) available have shown to have limited effect on overall survival. Due to the high risk of metastatic recurrence, evaluation of clinical and molecular characteristics is encouraged to guide surveillance care after local therapy, as there is very limited definitive data on the optimal follow up after initial treatment. Surveillance plans appear to be clinician and cancer center dependent and involve blood work, clinical examination and imaging at regular intervals. There are few guidelines to suggest change in frequency of follow up based on prognostic characteristics and thus, the utility of the score remains of limited value. Final Result: Two reviewers determined that the testing 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 medical 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: Urgent Care
Decision: Overturned

A 52-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient presented with symptoms of heart racing, sweating, tremors, chills, shortness of breath and blurred vision.  This constellation of symptoms is consistent with a variety of disorders such as acute coronary syndrome including cardiac ischemia and myocardial infarction, cardiac dysrhythmia, hypoglycemia, hypertensive emergency, and other disorders.  The symptoms that he was experiencing were sufficient to cause a reasonable prudent layperson to believe that an emergency medical condition existed.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee has requested  for an artificial disc replacement procedure for treatment of her degenerative disc disease.  Findings:  Three physician reviewers found that artificial total disc replacement remains an experimental procedure. There is insufficient evidence to demonstrate long-term safety and efficacy. There is also insufficient evidence to demonstrate that disc replacement results in better clinical outcomes than other available treatment. This patient has other standard treatments available to treat her condition that are likely to be more beneficial than artificial disc replacement.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female has requested authorization and coverage of an AMAS blood test and thermogram for treatment of pagets disease of the breast.  The health plan denied the enrollees request indicating that the requested tests are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested tests are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee requested occupational therapy (OT) at the frequency of one hour per week for medical treatment of the enrollees developmental delays.  Findings:  The physician reviewer found according to the documentation submitted for review, the patient has made significant progress in both speech and motor skills. Following nearly seven months of weekly OT, the patient had begun to reach the lowest levels of age expectations due to OT.  Thus, continued OT is medically necessary for further improvement.  Therefore, based on the medical literature cited above and the documentation submitted for review, the requested occupational therapy at the frequency of one hour per week is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested low dose chemotherapy treatments for treatment of his adenocarcinoma. Findings:  Three physician reviewers found that the patient has been diagnosed with adenocarcinoma of unknown primary.  The current medical evidence does not support the requested therapy for the treatment of this patient. In patients with side effects from chemotherapy, it is prudent and standard of care to deliver chemotherapy at 25 to 50% dose reduction.  However, extremely low doses of chemotherapy are not likely to be effective.  The superior efficacy of the proposed treatment has not been established by randomized, peer-reviewed, controlled clinical trials.  Thus, the superior efficacy of the requested low dose chemotherapy treatments in this clinical scenario has not been established.