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

An enrollee has requested reimbursement the genetic test DecisionDx-Melanoma. Currently, the DecisionDx-Melanoma genetic assay is not considered routine standard of care and is not endorsed by the National Comprehensive Cancer Network (NCCN) guidelines. There is a limited data to support its use in the care of patients with melanomas to effect health outcomes. There is literature to suggest it may be beneficial for patients with melanomas to predict whether there is risk for metastasis based on phenotype. However, there is a lack of data demonstrating improved patient health outcomes with guidance from the test results. The standard of care would require a wide local excision and follow-up skin surveillance. All told, the genetic test DecisionDx-Melanoma was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the genetic test DecisionDx-Melanoma was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The 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: 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an MRI of the cervical spine and an MRI of the lumbar spine for treatment of his medical condition.   Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedures. The patient can benefit from the anatomical studies of an MRI of the cervical spine and lumbosacral spine. The submitted clinical records document a history of neck pain with pain radiation into the upper extremities and low back pain with pain radiation into the lower extremity with previous MRI imaging of the cervical spine and the lumbar spine. The clinical records also document a change in the level of pain proximate to the request for repeat anatomical studies. Repeat studies are appropriate and indicated at this time in order to assess the extent of any incremental structural changes at the cervical spine and lumbosacral spine. Moreover, there is no documentation of any specific contraindications to MRI imaging such as ferromagnetic metal in the body or about the eyes or a pace maker. For these reasons, the requested procedures are medically necessary in the evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested procedures are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis often allows the reader to subtract dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional imaging protocol was likely of more benefit to the patient than had the exam been done with two-dimensional imaging alone. Final Result: Two 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 diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. Thus, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Given these findings, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the diagnostic procedure at issue 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned

The parent of a 16-year-old female enrollee has requested a magnetoencephalography (MEG for evaluation of the enrollees brain tumor. Findings:  Two physician reviewers found that MEG is utilized at tertiary epilepsy and neurosurgical centers. The procedure is useful in specific brain tumor surgery when tumors are in eloquent areas and there is a need to pre-operatively identify the central sulcus and Brocas area. MEG has been demonstrated to have superior capacity to adequately localize the margins of tumor in epileptogenic zones of brain tissue, allowing for more accurate surgical resection. MEG in this clinical setting is not considered investigational and was likely to be superior to any other method of pre-surgical evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 31-year-old male enrollee requested authorization and coverage of microlaser discectomy for the treatment of herniated discs.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that microlaser discectomy is not likely to be more beneficial for treatment of the enrollees herniated discs than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested for a magnetic resonance imaging (MRI) scan of the breast for evaluation of her breast mass.   Findings:  Two physician reviewers found that this patient is not in a high risk group of patients in which a breast MRI has been shown to provide a benefit. The patient has no known BRCA 1 or 2 gene mutation, no personal history of breast cancer, no history of ovarian cancer, and no family history of three or more affected first or second degree relatives that would give her a greater than 20% lifetime risk of developing cancer. In the absence of any of these findings, a breast MRI is not clinically indicated. Dense breast tissue is not an accepted indication for an MRI, nor would an MRI be beneficial for the evaluation of this patients breast mass.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested mental health residential treatment of his post-traumatic stress disorder. Findings:  The physician reviewer found that as stated by the American Psychiatric Association (APA), the treatment for PTSD should be delivered in the setting that is least restrictive, yet most likely to prove safe and effective. In addition, the UpToDate reference discussed appropriateness for discharge and stated that, the need for continued hospitalization is primarily determined by the presence of an acute health condition of sufficient severity that ongoing diagnostic or therapeutic intervention or careful monitoring is required. The medical records provided for review indicates this patient experienced a horrific event. Coupled with his pre-existing diagnosis of OCD, the patient required a very intensive approach to his care. He was admitted in the month and year specified, but by thte subsequent date, he began to show improvement. By the end of the month and year specified, the records showed that he was stable enough to be treated at a lower level of care. The patient was stabilized, was not in any acute distress, and was participating in treatment. The patients PTSD and OCD conditions were improved and he was functioning at a high enough level to return to school. There is no evidence of any behavior requiring 24-hour patient monitoring or intervention by the date indicated. Thus, the mental health residential treatment at the specified facility from the dates indicated was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Findings:  The physician reviewer found that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.An evidence based study of proton beam therapy did not endorse the routine use of proton therapy in the treatment of breast cancer. In addition, consensus group guidelines do not support the use of proton therapy in this setting. In the vast majority of cases, intensity modulated radiation or 3D conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. Also, there is no level I evidence to support the use of proton therapy for the treatment of breast cancer.In this case, the provider notes that comparative planning was performed. Due to image quality in the providers letter, however, the difference in mean heart dose between the photon and proton plans could not be distinguished. Therefore, there is insufficient data submitted that suggests that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. Furthermore, as noted above, consensus group guidelines do not support the use of proton therapy in this setting, and there is no level I evidence to support the use of proton therapy for the treatment of breast cancer. Under these circumstances, the requested proton beam radiation therapy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services were 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 radiation 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

A 25-year-old male enrollee has requested a wireless capsule endoscopy and dummy capsule for evaluation of his Crohns disease. Findings:  Two physician reviewers found that the peer reviewed medical literature provides ample data supporting the utility of a wireless capsule endoscopy in assessing small bowel Crohns disease (Cohen, et al). Use of a dummy, or patency capsule, is recommended when small bowel luminal diameter may be compromised as in this patients situation. Given this patients longstanding history of Crohns and extensive use of non-invasive methods to evaluate his condition, the requested wireless capsule endoscopy is likely to be more beneficial for acquisition of novel and useful information relevant to this patients care than any conventional alternative.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 12 weeks of Sovaldi and ribavirin for treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the 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 limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions (Class I, Level A recommendation). In addition, patients with genotype 2 hepatitis C should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks per AASLD/IDSA guidelines as a Class I, Level A recommendation. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, the requested treatment is medically necessary in this case.  Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for MRI of the lumbar spine. Findings:  The physician reviewer found that While routine imaging for low back pain may not be beneficial, Chou and colleagues found that diagnostic imaging is indicated if a patient with low back pain has severe progressive neurologic impairments, signs or symptoms suggesting a serious or specific underlying condition are present, or is a candidate for invasive interventions. Immediate imaging is recommended for patients with severe or progressive neurologic deficits, while imaging after a trial of treatment is recommended for patients who have minor risk factors for inflammatory back disease, vertebral compression fracture, radiculopathy, or symptomatic spinal stenosis. Subsequent imaging should be based on new symptoms or changes in current symptoms. The American College of Radiology (ACR) appropriateness criteria for lumbar imaging recommends imaging for patients presenting with red flags raising suspicion for a serious underlying condition. In the absence of red flags, imaging is indicated if persistent or progressive symptoms continue following six weeks of conservative management, if the patient is an interventional candidate, or diagnostic uncertainty remains. In this case, the patient complained of new onset low back and right hip pain with numbness radiating into the right groin and medial thigh, affecting his functional ability in daily activities of living. He was status post L3/4 decompressive surgery, and clinical examination demonstrated motor and sensory deficits. Based on current medical literature, given the onset of signs and symptoms of a significant underlying condition, and that the patient was a candidate for surgical treatment, the MRI was medically indicated. Therefore, MRI of the lumbar spine was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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: The patient has requested authorization and coverage for whole body F-18 fluciclovine (HCPCS A9588) positron emission tomography (PET) with computed tomography (CT) for attenuation (CPT 78816). The National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer state that F-18 fluciclovine PET/CT scan may be used to detect small volume disease in soft tissue. The American Urological Association (AUA) noted that there is limited data to support the utility of F-18 PET with CT to detect distant metastases. This patients records document a PSA of 5.0 in 2019 after treatment with radiation therapy in 2017 and PSA nadir in 2018. Based on the current data, F-18 PET/CT scan is not considered a generally accepted standard of care for management of patients with PSA recurrence after radiation. The standard of care in this clinical setting is a bone scan and CT to rule out metastasis and a prostate biopsy to evaluate for local recurrence if the metastatic work-up is negative. Therefore, the requested whole body F-18 fluciclovine (HCPCS A9588) PET with CT for attenuation (CPT 78816) is not medically necessary for evaluation of this patient.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 urology 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: An enrollee has requested reimbursement for a rhinoplasty procedure.This patient had a history of trauma to his nose, which caused nasal obstruction. His preoperative images show deviation of the external nose and depression of the nasal bone. Functional nasal reconstruction is a commonly performed procedure that involves septal and middle/upper nasal vault surgery. The submitted documentation supports the medical necessity of the services at issue. Therefore, the rhinoplasty procedure was medically necessary for the treatment of this patient. In this patients case, the records document an abnormal structure of the body. As noted above, there was deviation of the external nose and depression of the nasal bone. This abnormal structure of the body was caused by trauma approximately one year prior. The services at issue were performed to improve nasal breathing. Therefore, the surgery was performed to improve function. Thus, the rhinoplasty procedure was reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition and were reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 57-year-old male enrollee requested adalimumab (Humira) injections for treatment of his panuveitis.  Findings:  Three physician reviewers found that tumor necrosis factor (TNF) inhibitors such as Humira are being used increasingly more often in the management of severe ocular inflammation that is not responsive to standard treatments (Gupta, et al; Soheilian, et al). The records indicate that this patient has been receiving the standard of care treatment including high-dose steroids, T-cell inhibitors and anti-proliferative agents. The only two remaining options for this patient are to use alkylating agents or TNF inhibitors. Given the better safety profile, TNF inhibitors are the preferred treatment for this patient. As such, the requested Humira is supported as likely to be more beneficial for treatment of this patients panuveitis than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested for Residential Eating Disorder Treatment for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient does require ongoing and further care, but she does not meet the necessary criteria for the RTC level of care for her diagnoses. Her family should be able to provide the patient with adequate support while she is in an IOP.