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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that there is clinical support for the service at issue. According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.  Final Result: Two reviewers determined that the service at issue was 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 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: Overturned

A 68-year-old female enrollee requested thoracic anterior discectomy with decompression, including osteophytectomy (63077, 22610, 22802, 32100, 63046 and 63048) for medical treatment of her medical condition.  Findings:  The physician reviewer found that the medical records indicate that the patient has experienced pedicle fractures and vertebral body fracture above the levels of prior fusion.  Additionally, she has had multiple surgical procedures and has developed instability following the most recent surgical procedure.  A kyphotic deformity has developed, which is described as increasing in severity.  There is sufficient support for the requested services in this clinical setting.  The failure of posterior elements necessitates a combined posterior and anterior approach.  The current medical evidence supports the planned anterior and posterior exposures and extension of the prior fusion constructs to introduce stability to the patients spine.  All told, the requested thoracic anterior discectomy with decompression, including osteophytectomy (63077, 22610, 22802, 32100, 63046 and 63048) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested a tumor imaging PET/CT scan for an evaluation of his multiple myeloma. Findings:  Three physician reviewers found that Medicare has revised the guidelines for PET imaging and now approves the technique for staging and monitoring treatment for most tumors, including multiple myeloma. The advantage of PET over MRI and CT is that known lesions are assessed for metabolic activity with PET. Even when successfully treated, the abnormal findings on CT or MRI would still be present. The clinician would have no way to assess the importance of the lesion without knowing if it is active. Therapeutic decisions would depend on the presence/absence of active tumor, and PET is the only tool enabling clinicians to perform such an assessment. All told, PET/CT scan would be more valuable to this patient than any other method of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old man who developed symptoms of bowel obstruction in February 2004.  In May 2004 a colonoscopy was performed, which revealed a large colonic mass at 30cm from the anal verge that appeared malignant. A biopsy was obtained, which did not show malignancy. A CT scan revealed a mass of 11x13 cm in the sigmoid colon contiguous with rectosigmoid and having invaded the dome of the bladder. Air was also described in the bladder suggestive of direct involvement of the urinary bladder with rectovesicular fistulous formation. The CT scan suggested diverticular disease. Surgery was recommended, but the patient refused and requested an oncologic referral.Both the medical oncologist and the radiation oncologist recommended an operative approach as the main approach initially to determine the grade and the stage of the cancer. The patient refused. The patient requested proton beam therapy and agreed to start chemotherapy initially and external beam irradiation subsequently. Chemotherapy was started on 6/7/04. Radiation therapy was started on 9/13/04. The patients symptoms improved.Surgery was again recommended when a CT scan of 1/5/05 showed significant regression in the size of the tumor from 8-9cm on 5/24/04 to 4-5cm. The fistula to the bladder persisted with the pressure of air in the bladder. The patient has no imaging evidence of distal metastases.There is no objective evidence of the type and the grade of this cancer. The stage of the cancer is not determined and this can only be done surgically. Thus, the precise location or extension of the patients cancer is not known. Proton beam therapy is primarily used on proven and documented cancer in confined organs and with confined margins, e.g., the prostate gland. The sigmoid colon and the bladder dome do not meet these criteria. In addition, given the size of sigmoid cancer it is generally associated with extensive lymph node metastases, which would be impossible to adequately treat with proton beam therapy. As such, the medical community has not used proton beam in cancers of the sigmoid colon. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks.  Per the medical evidence, the requested treatment with Harvoni is medically indicated 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Tomosynthesis allows the provider to separate various layers of breast tissue to better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast tissue. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. As such,  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 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: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested for neurobiofeedback for treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that there is insufficient evidence that neurobiofeedback will have clinical value in this setting. As noted by Monastra and colleagues, additional randomized controlled trials are needed to provide a better estimate of the efficacy of biofeedback treatment. Heinrich and colleagues noted that while neurobiofeedback may present as a valuable treatment module for neuropsychiatric disorders, further controlled studies are necessary to establish efficacy.  The American Academy of Child and Adolescent Psychiatry practice guidelines provide detailed treatment modalities for attention deficit/hyperactivity disorder; neurobiofeedback is not included among the recommended options.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a two-year-old female enrollee has requested a standing frame for treatment of the enrollees cerebral palsy. Findings:  Three physician reviewers found that the submitted documentation and relevant literature supports the use of a standing frame in this clinical setting. This patient has cerebral palsy and cannot stand or attempt ambulation unless a supportive system is in place. This patient is also fitted with ankle foot orthosis (AFO) to aid in prevention of ankle foot contractures. According to Gibson and colleagues standing frames in non-mobile children significantly improved ankle contractures. Moreover, within the rehabilitation medical community it is well-accepted that the standing position in immobile children will improve cardiac tone, help prevent vasovagal syncope, reduce loss of bone density and improve pulmonary hygiene. Thus, the standing frame is likely to be more beneficial for the treatment of the patients medical condition than other available options.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee requested whole body positron emission tomography (PET) scan (CPT code 78813) for medical evaluation of her left choroidal spindle cell melanoma.  Findings:  Three physician reviewers found that this patient has a rare disease, ocular melanoma. The Collaborative Melanoma Study (COMS) demonstrated equivalent survival in patients treated with brachytherapy versus enucleation (Diener-West, et al). Thus, this patient was appropriately treated for a small choroidal tumor. The COMS trial showed that 47% of patients will develop metastatic disease even after enucleation or brachytherapy in 11 years of follow-up and about one-half of these patients develop liver metastases. This patient had a molecular profile that suggested the patient is at high risk for the development of metastatic disease. Accordingly, her providers have recommended performance of a whole body PET to evaluate for additional lesions. Thus, the requested follow-up PET scan (CPT code 78813) is clinically indicated and likely to be more beneficial than any available alternative for further evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ArthroFLEX allograft used during surgery. The records provided for review document that this patient developed marked stiffness of the proximal radioulnar joint as well as the elbow due to trauma with subsequent heterotopic ossification. This condition caused the bony surfaces to stick to one another due to the ossification of the tissues around the bone. The provider dissected the capsule of the elbow and removed the calcified tissues. To ensure that the released tissues did not stick together and result in recurrent stiffness of the proximal radioulnar joint and elbow, the provider performed an interposition arthroplasty. As noted in the medical literature, acellular dermal matrix ArthroFLEX can be used in this clinical setting to prevent the bone surfaces from sticking and to help preserve motion. All told, the ArthroFLEX allograft used during surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the the ArthroFLEX allograft used during surgery was likely to be more beneficial for you than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 orthopedic surgery 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: A patient has requested reimbursement and prospective authorization and coverage for additional theta-burst transcranial magnetic stimulation (TMS) services rendered from April 2017 forward. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the patients major depressive disorder (MDD). The submitted documentation does not support the medical necessity of the services at issue. The patient received 47 sessions of transcranial magnetic stimulation (TMS) from January 2017 through March 2017. The patient had a good response to the TMS treatment, and the patients PHQ-9 scores dropped from 20 to five. The patient received an additional 20 sessions of TMS from April 2017 through June 2017. After April 2017, the patients PHQ-9 scores were five and below with one exception on April 12, 2017 of a PHQ-9 score of a six. The patients depression after April 2017 was either in remission or he was having mild depressive symptoms. It appears that the TMS treatments from April 2017 through June 2017 were used as maintenance sessions for the patients depression. There is ongoing research into the study of maintenance TMS for depression. However, maintenance TMS treatment for depression is still being researched and further studies are needed to determine efficacy. Therefore, it is not currently standard of practice to continue to administer TMS treatment after a significant response to treatment. Thus, additional theta-burst transcranial magnetic stimulation (TMS) services rendered from April 2017 forward were not and are not medically necessary for the treatment this patient.Final Result: The reviewer determined that the services at issue were not and are not services at issue 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 10 treatments of MLS laser therapy for treatment of the enrollees foot pain. Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent medical guidelines for this case, the 10 sessions of MLS cold laser therapy were not medically reasonable or necessary for treatment of this patients Mortons neuroma. MLS cold laser therapy has not been proven to be significantly effective in the treatment of Mortons neuroma pain. While studies show some promising efficacy for this modality, there is a lack of double-blind placebo-controlled studies on Mortons neuroma to demonstrate its superior effectiveness versus surgical excision of neuroma, alcohol injection sclerosis of neuroma, or orthotic therapy with metatarsal raise pads. For these reasons, the 10 treatments of MLS laser therapy was not medically necessary for this patients medical condition. Final Result: The reviewer determined that the services at issue 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 podiatry 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 patients parent has requested authorization and coverage for 10 hours of 1:1 applied behavior analysis (ABA) therapy. The records provided for review document that this patient presents with a history of autism, attention-deficit/hyperactivity disorder (ADHD), and associated behavioral issues. The provider has charted minimal goals in the current treatment plan and the patients challenging behaviors are at near zero levels. The provider has recommended four hours of ABA services per week, which is appropriate given the patients current goals and behavioral issues. The patients caregivers have requested an increase in service intensity. However, there is a lack of supporting assessments or documentations that support an indication for 10 hours of ABA services per week. The Council of Autism Service Providers (CASP) highlighted the scope of focused treatment. Per CASP, treatment intensity will vary with each client and should reflect the goals of treatment, specific client needs, and response to treatment. According to researchers, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on this definition, the patient fails to meet criterion (c) and (d). Specifically, the caregivers request for 10 hours per week is not consistent with the providers request for four hours per week. In this situation, the providers request is within the treatment guidelines outlined by CASP. For these reasons, the requested 10 hours of 1:1 ABA therapy is not medically necessary for 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 licensed B.C.B.A, board certified in psychology, 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 38-year-old male enrollee has requested for Xolair for treatment of his asthma. Findings:  The physician reviewer found that a study found that patients with moderate to severe asthma who received Xolair reduced their steroid use. Given this patients previous failure of conventional combination therapy and strong contraindication to corticosteroid use due to his central serous chorioretinopathy, Xolair is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested a follow-up ultrasound for evaluation of her medical conditions. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure. Although this pregnancy is complicated by advanced maternal age and uterine fibroids, there is no specific suspicion for abnormal fetal growth from the clinical exams. The finding of an enlarged fetal abdominal circumference at 31 weeks is suggestive of potential fetal macrosomia. According to the American Institute of Ultrasound in Medicine (AIUM) obstetrical ultrasound guidelines, The abdominal circumference or average abdominal diameter measurement is used with other biometric parameters to estimate fetal weight and may allow detection of intrauterine growth restriction or macrosomia. This finding, however, does not necessitate further ultrasounds unless fundal height measurements are more than 2 weeks ahead of expected or if the estimated fetal weight is more than 4,000 g or 4,500 g (ACOG Practice Bulletin No. 101). Since the estimated fetal weight at 31 weeks was normal, this degree of excess fetal growth does not warrant an additional ultrasound. Given these factors, the request for the follow-up ultrasound is not medically indicated. All told, the medical necessity of the requested diagnostic procedure has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested a power wheelchair for treatment of his paraplegia.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested power wheelchair. This patient has chronic degenerative disorders, a history of polio with weakness and atrophy of his lower extremities and post-polio syndrome. The patient has chronic low back pain from muscular imbalance and weakness of his lumbar muscles. He has degenerative arthritis of his shoulders and carpal tunnel syndrome from overuse syndrome related to manual wheelchair mobility. These pathologies tend to progress in severity as an individual ages, making mobility more challenging and power mobility medically necessary. The patient ambulates only short distances with crutches or uses the manual wheelchair with discomfort. Additionally, the patients home does support the use of a power wheelchair and there are no medical contraindications. A power wheelchair would allow safe mobility inside and outside of his home without worsening his musculoskeletal pathology. All told, the medical necessity of the requested equipment has been established.