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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDX-Melanoma multi-variate gene expression assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees  cutaneous melanoma.Findings:  Researchers found the standard protocol for an intermediate thickness tumor, like the one this patient has, does not include a recommendation for a workup with molecular genetic testing. Although the testing has shown some promising results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. In addition, the protocol would be a wide local excision and possibly a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. Clinical studies are lacking at this time to indicate that the results of the molecular testing will make a difference in the treatment or morbidity or mortality of the patient. The only exception to this would be with discordant results. For these reasons, DecisionDX-Melanoma multi-variate gene expression assay provided was not likely to have been more effective than the available standard options of evaluating this patients medical condition.  Final Result: Two of the three reviewers have determined 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:  All three reviewers are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested for a PET scan for evaluation of her ovarian cancer. Findings:  The physician reviewer found that PET scans for the initial evaluation of recurrent ovarian cancer have not yet been shown to be of more beneficial than standard imaging. As this patient has not had any other imaging to evaluate for recurrent/metastatic disease, a PET scan is not medically indicated for this enrollee at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Medtronic 670G insulin pump with continuous glucose monitoring system. A continuous glucose monitoring system (CGMS) is one of several devices approved by the U.S. Food and Drug Administration that records blood sugar levels at repeated intervals continually.  CGMS may identify fluctuations and trends that would otherwise go unnoticed, preventing hyperglycemia and hypoglycemia. Lane and colleagues found that CGMS may be used to tighten glycemic control, and may promote safer and more effective glycemic control than self-monitoring of blood glucose. CGMS can lead to even greater improvement when used in conjunction with insulin pump therapy. In this case, the patient is an insulin-dependent diabetic currently using a MiniMed 630G pump with less than adequate control. Her hemoglobin A1C on 7/21/20 was 10.9, with a history of elevated blood glucose. Notably, on 4/1/20, her blood glucose was greater than 500, and she has a history of diabetic ketoacidosis. In this case, tighter control of 24-hour blood glucose would be beneficial. In this regard, the MiniMed 670G pump, a hybrid closed-loop insulin delivery system that uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor, would help the patient optimize her glycemic control, thereby reducing the likelihood of long-term diabetic complications. Therefore, the Medtronic 670G insulin pump with continuous glucose monitoring system is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee requested Avastin for medical treatment of his rectal cancer.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Avastin has been approved for use, along with chemotherapy, in metastatic colorectal cancer.  However, the current medical evidence does not support the continuation of Avastin alone in this clinical setting.  There is a lack of data indicating that Avastin alone as maintenance therapy is likely to beneficial in this patients case.  Further, it is not clear that this patients clinical status is a maintenance situation.  This patient would be more likely to derive benefit from a new line of chemotherapy rather than continuation of Avastin alone.  All told, the requested Avastin is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin (IVIG). Findings:  The physician reviewer found that selective antibody deficiency with normal serum IgG concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of IgG and IgG subclass. IgG replacement therapy with IVIG or subcutaneous immunoglobulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and antibiotic treatment. Evaluation of serum antibody titers to pneumococcus includes obtaining serum antibody titer prior to immunization, and then again three to six weeks after immunization with polyvalent pneumococcal polysaccharide vaccine. A failed overall challenge test is defined as failure in seven or more serotypes (30% or more) in patients age six years or older. Despite the fact that this patient has normal levels of IgG, her response was abnormal to vaccine challenge with post-vaccination pneumococcal (polysaccharide) titers. In addition, the patient also has a history of frequent, significant infections requiring antibiotics and hospitalization. The current medical evidence supports the requested medication in this clinical setting. Therefore, IVIG is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine and allergy and immunology 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 percutaneous tibial nerve stimulation. Findings:  Two of the three physician reviewers found the medical evidence supports the requested services in this clinical setting. This patient has failed multimodal primary and secondary treatments for her condition. Thus, percutaneous tibial nerve stimulation is appropriate in this patients case. Percutaneous tibial nerve stimulation is considered to be an appropriate salvage therapy for patients with intractable lower urinary tract symptoms, including frequency and nocturia. In sum, percutaneous tibial nerve stimulation is likely to be superior over other available treatment options.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 urology 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

The parent of a 17-year-old female enrollee has requested rhinoplasty for the treatment of the enrollees nasal obstruction/deformity secondary to post-traumatic nasal deformity with nasal bone fracture. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates a structural abnormality in the patients nose. This structural abnormality was the result of trauma. The proposed procedure is being performed to improve the function of breathing. The procedure will offer more than a minimal improvement in the appearance by straightening the septum and correcting the collapsed lateral nasal wall (middle nasal vault). As such, the proposed rhinoplasty meets the requirements of reconstructive surgery as defined by California law. The requested procedure is also medically necessary in this case. Proper correction of the twisted nose with a significant caudal septal deviation, collapsed middle vault, and fractured nasal pyramid (bones) requires an open structure rhinoplasty approach. The patients breathing problems cannot be corrected with a septoplasty alone since the collapsed upper lateral cartilage must also be corrected using spreader grafts. In addition, osteotomy and straightening of the collapsed nasal bones must be carried out. Finally, in order to prevent the need for another operation in a few years, the significant deviation of the caudal septum has to be corrected by cutting the cartilage and re-positioning it into the columella and securing it to the lower lateral cartilage and the nasal floor. This can only be accomplished using an open rhinoplasty approach.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of breasts (CPT 77046). The American College of Radiology (ACR) recommends screening breast MRI in women at high risk for breast cancer on the basis of family history or genetic predisposition. The ACR appropriateness criteria for breast cancer screening categorizes women with 20% or greater lifetime risk of breast cancer as high-risk. For such women, breast MRI without and with intravenous  contrast is usually appropriate. Spick and colleagues found that short-term follow-up MRI at intervals of six, twelve, and 24 months of MRI-detected probably benign (BI-RADS 3) lesions remained a strong tool with which to detect suspicious lesions, and monitor interval changes in size, morphology, or enhancement that may be indicative of malignancy. In this case, the patients provider calculated her lifetime risk at 26%, placing her in the high-risk category. Therefore, MRI of breasts (CPT 77046) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 diagnostic radiology 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 52-year-old female enrollee has requested  a repeat colonoscopy and a capsule endoscopy for evaluation of her irritable bowel syndrome and functional disorder of intestine. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based upon the medical records, this patients symptoms are consistent with irritable bowel syndrome.  There is a lack of support for the requested repeat endoscopy or capsule endoscopy in this clinical setting.  This patient has been appropriately and comprehensively evaluated.  Per the current medical evidence, she does not meet accepted criteria for capsule endoscopy or guidelines for a repeat colonoscopy.  All told, the requested repeat colonoscopy and capsule endoscopy are not medically necessary for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for real time remote heart monitoring services. Findings:  The two physician reviewers found that based on the records provided, this patient had a syncopal spell.  In this circumstance, an evaluation for a dysrhythmia was recommended by the treating provider to better assess the patient and identify a treatment plan. As such, a prolonged serial 48-hour Holter monitoring or off-line self-activated or auto-triggered cardiac event monitoring would have been sufficient in recording cardiac rhythm. There was no documentation to indicate this patient was not able to effectively manage the self-activated standard devices. There was no record to indicate that these devices have been tried and failed.  Some national organizations consider Holter monitoring and/or patient-activated or auto-triggered event recorders as appropriate initial tests and the standard of care for evaluation of dysrhythmias. As such, continuous real time monitoring by telemetry services are not likely to be more effective than the standard available monitoring devices. Off-line analysis of a patient-activated or auto-triggered event recorder should be sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety.  The current medical literature does not support that immediate recognition and reporting of dysrhythmias through a call center, provided by real time mobile telemetry services, improve health outcomes when compared to standard monitoring techniques.   Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this patients case. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. All told, Vemlidy 25 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cosentyx 300 mg injections administered every 28 days in the physicians office. This patients records document a history of plaque psoriasis as well as rheumatoid arthritis. The patients provider reported that treatment with methotrexate, topical corticosteroids, and Humira failed to adequately control the patients condition. The patient has started treatment with Cosentyx with good results. The U.S. Food and Drug Administration (FDA) approved Cosentyx for the treatment of patients with chronic plaque psoriasis. The records provided for review document that this patient with plaque psoriasis has been treated with conventional medications without substantial symptomatic improvement. There are data in the medical literature demonstrating that Cosentyx is safe and efficacious in the treatment of patients with plaque psoriasis. Augustin and colleagues concluded that, This meta-analysis strengthens existing evidence on the clinical effectiveness of secukinumab in patients with moderate-to-severe PsO [plaque psoriasis], demonstrating high drug survival rates, high levels of patient-reported outcomes, and good tolerance. However, the in-office injections are not medically necessary. Cosentyx is FDA approved for subcutaneous self-injection. The records do not demonstrate that the patient is unable to perform self-injections. Therefore, the requested Cosentyx 300 mg injections administered every 28 days are medically necessary for treatment of this patient, but the requested services of the physicians office are not medically necessary for the Cosentyx injection administration. Final Result: The reviewer determined that the requested medication, but not the requested services, is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male has requested therapeutic facet joint injections for treatment of his severe low back pain.  Findings:  The physician reviewer found that this patient has documented facet pathology and had a positive response to previous medial branch blocks and steroid blocks. In this particular case, the patient has failed treatment with other standard therapy. Additionally, the peer reviewed medical literature supports the utility of therapeutic facet joint injections for low back pain due to facet arthropathy and lumbar spondylosis, as is the case with this patients chronic medical condition.Manchikanti, et al. conducted a randomized, double-blind, controlled-trial to determine the clinical effectiveness of therapeutic local anesthetic lumbar facet joint nerve blocks with or without steroid in managing chronic function-limiting low back pain of facet joint origin, and concluded that therapeutic lumbar facet joint nerve blocks, with or without steroid, may provide a management option for chronic function-limiting low back pain of facet joint origin. Additionally, facet joint blocks appear to have a beneficial medium-term effect in one third of patients with chronic lower back pain and may therefore be considered a reasonable adjunct to non-operative treatment (Gorbach, et al.)There is strong support in the medical literature for therapeutic facet joint injections for treatment of chronic spinal pain due to facet arthropathy. Per the patients medical records, facet joint injections were previously shown to provide adequate relief of the patients back pain. Standard therapy has failed to provide the same results as facet joint injections. Therefore, therapeutic facet joint injections are medically necessary treatment for the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing.Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The initial biopsy report noted follicular lesion of undetermined significance.  The genetic testing performed was beneficial in avoiding an unnecessary surgical procedure.  Genetic testing is generally considered standard protocol on fine needle aspirations done on thyroid nodules.  There is sufficient literature demonstrating that this test can be easily performed to avoid needless surgeries.  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 physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vision restoration therapy for treatment of the enrollees vision changes status post cerebrovascular accident (CVA). Findings:  The physician reviewer found that currently, there is a lack of consensus on the usefulness and effectiveness of such vision therapy after stroke. Strength of this evidence is not yet sufficient to warrant clinical recommendations. Results with vision therapy has not been demonstrated to have a role in the standard of care. Given the paucity of data supporting improved patient outcomes, the requested vision restoration therapy is not medically necessary for treatment of this patients vision changes. 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 ophthalmology 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.