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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin and clinical examinations. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and oftentimes are referred to medical oncology for adjuvant medical therapy. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a pelvic varicosity embolization procedure. Findings:  The physician reviewer found that Pyra and colleagues report that embolization is a minimally invasive, effective and safe treatment for pelvic congestion syndrome (PCS). In a study of 113 patients with PCS, Nasser and colleagues report that transcatheter embolization is a safe and effective treatment for PCS. In this case, the patients clinical findings and imaging studies suggest PCS. In this clinical setting, gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. Therefore, a pelvic varicosity embolization procedure is likely to be more beneficial than any other available standard treatment for the patients medical condition.Findings:  Two of the three physician reviewers found the requested pelvic varicosity embolization procedure 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 service is 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 reviewer 1, 2, and 3 are board certified in obstetrics and gynecology 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 requested vertebral axial decompression for treatment of his medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patient did not report leg pain per the submitted documentation.  The office notes indicate that the patients problem was mechanical and not neurological.  Therefore, the medical evidence does not support vertebral decompression given this patients diagnoses.  All told, the superior efficacy of vertebral axial decompression performed has not been established. Final Result: Two reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in chiropractic care and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for Norditropin Flexpro (somatropin) human growth hormone. This patient does not have a known hypothalamic-pituitary defect or deficiency of at least one pituitary hormone other than growth hormone, which would allow the diagnosis of growth hormone deficiency in the absence of growth hormone stimulation testing. In addition, she does not have a medical condition for which growth hormone is recommended. This patient has normal laboratory results, delayed bone age, and her predicted adult height is just a few inches below the mean parental height. Current guidelines support treatment with growth hormone therapy for patients with a height that is two or more standard deviations below the mean for age and gender. In addition, she has normal interval growth. The patients provider has recommended observing her growth over time instead of treating with growth hormone. Given these findings, the requested Norditropin Flexpro (somatropin) human growth hormone is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric endocrinology 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: The enrollee has been diagnosed with osteoporosis and gastritis and is requesting anabolic therapy with Tymlos. Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the enrollee's medical condition. Therefore, the Health Plans denial should be upheld.  The enrollee has age-related osteoporosis and requires surgical intervention once her bone mineral density (BMD) has improved. The enrollee has had a significant BMD decline of 6.1% since 2014. The enrollee has a lumbar spine T-score of -3.4, which is consistent with osteoporosis, and left hip T-score of -2.5, which is consistent with osteopenia. Previous therapies that have been tried and failed include calcium and vitamin D supplement. The provider noted that oral bisphosphonates are contraindicated due to Barretts esophagus without dysplasia. Tymlos therapy is an anabolic medication which can lower the risk of osteoporotic fractures by improving the bone strength. This patient has post-menopausal osteoporosis but does not have a history of fragility fractures. She has a documented decrease in BMD scores, however, she has not previously been treated with anti-resorptive therapy for osteoporosis. Specifically, the enrollee has not reportedly tried and failed therapies like Prolia or Reclast prior to considering anabolic therapy such as Tymlos (Cosman, et al.). Therefore, anabolic therapy with Tymlos is not supported as medically necessary for treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheldCredentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for advanced lipoprotein testing. The enrollee has been diagnosed with dyslipidemia and vitamin D deficiency.  He underwent advanced lipoprotein testing. The medical literature indicates that generally patient care issues related to screening, diagnosis, and treatment are based on the results of the measurement of serum lipids, which is generally accomplished by obtaining a lipid profile.  On occasion, measurement of serum lipoproteins is necessary for one or more of these purposes. There are strong associations between total LDL particle concentration and cardiovascular disease, which provide a rationale for advanced lipoprotein testing for total LDL particle numbers in cardiovascular risk assessment and treatment. The lipid profile and its components (total cholesterol, low density lipoprotein cholesterol, high density cholesterol, and triglycerides) are some of the most commonly ordered laboratory tests in clinical practice.  The most common indication for this test (or its components) is for aiding the process of determining cardiovascular disease event risk.  The enrollee underwent extensive laboratory testing and had a diagnosis of dyslipidemia.  The records that were provided indicated that the enrollee was to undergo advanced testing to determine cardiovascular risk.  The rationale for advanced testing with the particles included was not noted.  The literature indicates that the most commonly ordered tests are total cholesterol, low density lipoprotein cholesterol, high density cholesterol, and triglycerides. A search of the guidelines failed to indicate there was a recommendation of testing for advanced lipoproteins to establish heart disease risk.  The literature indicates therapies targeting HDL and HDL composition have been disappointing to date. It remains to be determined whether these tests incrementally add to cardiovascular risk predicted by traditional risk factors.  More importantly, it has yet to be determined whether treatment strategies guided by, or targeting, these measures improve cardiovascular outcomes. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiovascular Disease and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 48-year-old female who has a long history of back pain secondary to degenerative disc disease. A discography showed concordant axial back pain and annular degeneration at L3-4 and L4-5 disc levels. Conservative therapy has failed to provide pain relief. Therefore, the patients provider has recommended the patient undergo intradiscal electrothermal therapy (IDET). The Health Plan has denied authorization and coverage for IDET on the basis it is considered experimental.IDET remains a controversial treatment for degenerative disc disease. Several cadaveric studies demonstrate the IDET procedure does not heal the disc very well. Review of the medical literature reveals several studies showed little to no efficacy of the IDET procedure. IDET is not the standard of care and it is not in the mainstream of lumbar degenerative disc disease treatment, particularly when there is more than one disc involved. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 48-year-old woman with chronic back pain secondary to degenerative disc disease. A request has been made for an IDET procedure. The Health Plan has denied the request.There is no information available to warrant and support the use of IDET. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. In this community, when IDET has been used the results have been poor. As such, IDET cannot be recommended until the efficacy of the procedure has been established. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 48-year-old woman with a history of degenerative disc disease. She has undergone conservative treatments with no long-term benefit. The patients provider has recommended the patient undergo an IDET procedure. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.IDET remains an unproven procedure without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of chronic back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male has requested coverage for orthopedic shoes and lift elevated heel for treatment of his flat feet.  Findings:  The physician reviewer found that per the submitted documentation, the requested equipment is medically necessary for the treatment of this patient.  As noted by the patients physician, his bones are too immature for surgical correction.  Therefore, treatment must be conservative in nature.  As stated in the progress notes, this patient suffers with bilateral foot pain caused by an anatomical misalignment of his foot bones.  It is documented that he has congenital pes planus with a tight heel cord and subtalar joint valgus.  In order to realign the joints of the feet and remove excessive pressure from the painful areas, functional orthotics and corrective shoe gear are necessary.  Per the current medical evidence, in this clinical situation, the best way to realign the foot is through the use of orthotics and shoe modifications.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old male enrollee requested authorization and coverage of surgery for the treatment of metastatic osteosarcoma.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the injectable medication Durolane to 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 tried and failed other conservative treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs), intraarticular corticosteroid injections, and bracing. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, the injectable medication Durolane to the right knee is medically necessary for the 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.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for nerve block injection. There is adequate data to support a role for occipital nerve blocks for the treatment of this patients headache with occipital neuralgia. However, this patients records do not document that less invasive treatment options were exhausted prior treatment with nerve block injections. Specifically, there is no mention of the completion of behavior therapy, despite much research to support its use. In addition, not all medications in the various classes have been optimized. Moreover, there is a lack of support for treatment with steroid injections while the patient is taking oral steroids. For these reasons, the nerve block injection was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  Reviewer 1, 2, and 3 are board certified in anesthesiology with subspecialty certification in pain management 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

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees expressive and receptive speech delay. Findings:  The physician reviewer found that this patient has an identified delay in receptive speech of 30% and expressive speech of approximately 35%, with additional developmental delays in adaptive, social-emotional and overall development. Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for glioma removal treatment using stimulated Raman histology (SRH) technique. SRH is a diagnostic pathology technique used to make an intraoperative diagnosis and aid in surgical decision making. Researchers published a prospective cohort study on 21 patients who underwent surgical resection of glioma. The tumor specimens were evaluated by SRH and via standard frozen histopathology and then compared to the gold standard of permanent histopathology. These authors reported no difference in diagnostic accuracy between SRH and frozen evaluations, but the time to diagnosis was significantly shorter for SRH. The authors concluded that SRH may serve as an adjunct to conventional histopathology and expedite intraoperative histopathology. Hollon and colleagues performed a multicenter prospective trial and reported that SRH is a means of delivering expert-level intraoperative diagnosis where neuropathology resources are scarce and improving diagnostic accuracy in resource-rich centers. This patients records document evaluation and treatment involving at least one major medical center, which indicates that a neuropathologist will be available for intraoperative diagnosis. Based on the current peer-reviewed medical literature, the requested glioma removal treatment using SRH technique is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the glioma removal treatment using SRH technique 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in neurological surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested for bilateral reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that the constant pull of heavy breasts against the upper torso is a mechanical problem, and conservative treatments have been shown to be ineffective for symptomatic macromastia. .  Non-operative treatments were unlikely to improve her pain, and surgery provided the only real chance for symptomatic relief. Weight loss generally does not improve the symptoms of macromastia. In fact, breast reduction is proven to facilitate weight loss because the postoperative breast reduction patient is better able to exercise. The concept supported in the medical literature is that patients who present with the typical symptoms of macromastia and who have a confirmatory exam benefit greatly from breast reduction surgery. As noted by Kerrigan, weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms were unlikely to improve unless she had a breast reduction.  The reduction was above the amount recommended in the literature for a reduction to be considered medically necessary. The peer-reviewed literature strongly indicates that this patients breast reduction was medically necessary.