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: Three physician reviewers found that breast 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breasts have been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Three 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  In about one-third to one-half of cases, a paraganglioma is a component of an inherited syndrome. Based on available data, genetic screening is advised for all patients diagnosed with a paraganglioma.  Diagnosing a genetic syndrome is important for deciding on further management to prevent malignancies.  All told, the requested gene testing is likely to be of greater benefit than other methods of evaluating this patient.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested for an eight week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. The guidelines note that treatment duration of eight weeks can be considered in treatment-naive patients without cirrhosis who have a baseline viral load less than 6 million IU/mL. Since this patient is treatment-naive and has a viral load of less than 6 million IU/mL, the requested eight week course of Harvoni is medically necessary.  Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 31-year-old female enrollee has requested the Mirena intrauterine device (IUD) for treatment of her endometriosis. Findings:  The physician reviewer found that this patients gynecologist has recommended Mirena IUD system for the treatment of severe pelvic pain associated with endometriosis. A number of small studies have reported the beneficial effects of the levonorgestrel-releasing intrauterine system on pain symptoms of endometriosis. However, these findings need to be confirmed with well designed adequately controlled prospective studies. Further, the extent of benefit and the types of endometriosis most likely to respond have yet to be established in larger randomized trials. Currently there is insufficient evidence to support the use of Mirena in the primary treatment or secondary prevention of endometriosis and its associated symptoms of pelvic pain. As such, the requested Mirena IUD has not been established as medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested Xifaxan for treatment of her irritable bowel syndrome (IBS).  Findings:  The physician reviewer found that the link between the patients symptoms and the presence of SIBO has not been clearly established based on the clinical findings presented in the records (Singh and Toskes). However, if her treatment plan included a course of antibiotics for 7-10 days there are several more standard alternatives. The proposed use in this patients care would be an off-label use of Xifaxan. Although the medication has a very favorable side-effect profile, its use is not considered standard of care in this clinical setting. Proven therapies include a quinolone or preferably metronidazole combined with trimethoprim/sulfamethoxazole (TMP/SMX). For these reasons, Xifaxan has not been established as medically necessary in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxymorphone HCL (10 mg) 90 tablets every 15 days. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has intractable migraines. He has tried and failed several other opioid medications and is currently on several oral prophylactic agents and non-opioid therapy including Botox and Emgality injections. He is under the care of a neurologist and a pain management specialist. The patient has been consistent with monthly appointments and his CURES report and urine drug screens have been appropriate with no evidence of drug seeking behavior. Given that the patient is currently experiencing relief with the requested medication, and that the provider and patient are following current evidence-based guidelines pertaining to the use of opioids for the management of non-cancer pain, the requested medication is medically indicated. Therefore, oxymorphone HCL (10 mg) 90 tablets every 15 days are 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 anesthesiology with sub-specialty certification in pain medicine 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for hydrocodone bitartrate/acetaminophen (Norco) 5-325 mg tablets. The Centers for Disease Control and Prevention (CDC) guidelines report that, Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. The CDC noted further that, If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards (FSMB) state that, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has a hx of chronic pain due to cervical and lumbar spondylosis as well as osteoarthritis. The records document that the patient has been treated with non-opioid therapy and a joint injection, which have been ineffective. The patient has reportedly failed to follow-up with providers for further adjustment of the treatment plan. The provider did not recommend chronic opioid therapy and noted that the risks outweigh the benefits for this patient. Per the CDC and FSMB recommendations, continued treatment with opioid therapy is not supported for this patient. The patient is a candidate for further treatment with non-opioid therapeutic options. All told, the requested hydrocodone bitartrate/acetaminophen (Norco) 5-325 mg tablets are 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous immunoglobulin (IVIG) 30 grams (Gammagard 30 grams) for treatment of the enrollees multiple sclerosis. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Intravenous immunoglobulin therapy has sometimes been utilized for the treatment of multiple sclerosis exacerbation when traditional therapies have failed. The use of IVIG as a primary disease modifying treatment is currently not recommended and is not considered the standard of care. For most cases, IVIG is used in patients who have tried and failed treatment with currently available monoclonal antibody therapies such as Tysabri. As such, there is a lack of support in the medical literature for the use of IVIG as a first line treatment of multiple sclerosis. In this patients case, the submitted records do not show that Tysabri has been tried and failed for the treatment of this patient. Therefore, IVIG 30 grams (Gammagard 30 grams) twice per week, for one year, is not medically necessary for treatment of this patients multiple sclerosis.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the FoundationOne blood test.  Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective therapies may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling such as with FoundationOne is likely to be more beneficial than any available standard therapy. For these reasons, the FoundationOne blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that FoundationOne blood test provide was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings: Two reviewers found that there is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated use of advanced lipoprotein testing for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology (ACC) do not support the use of advanced lipoprotein testing. According to the ACC, there is a lack of data to indicate a benefit for advanced lipoprotein testing over the basic lipid profile. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy.Final Result: Two reviewers found that testing 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: All three 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

A 19-year-old male enrollee is requesting residential care for the treatment of his schizoaffective disorder, oppositional defiant disorder, cannabis abuse and alcohol abuse. Findings:  The physician reviewer found that this patient is seriously ill and is clearly in need of intensive psychiatric services. He was not as overtly psychotic, and his paranoia had diminished. His mood was controlled, and there was no suggestion of suicidal or homicidal ideation. However, his behavior continued to be a clinical issue. His interaction with peers suggested that there remained a thought disorder which may or may not have been of psychotic proportions, but which clearly required continued residential treatment. His behavior was often inappropriate and dangerous both to himself and to others. The patient was unpredictable. He was unable to follow a schedule without redirection. His aberrant thought disorder prevented him from acting in a socially acceptable manner much of the time. Although he was making progress, and even anticipating discharge, he was not yet ready for lesser level services. The patient required residential treatment. Such care was medically indicated. Discharge to a lesser level of services would have been inappropriate, unsafe and imprudent.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested  substance abuse sub-acute residential treatment rehabilitation services  for treatment of the enrollee's opioid dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records did not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, community programming, family counseling, school-based services or evidence-based psychotherapies and pharmacological strategies targeting his addictive illness and depressive symptoms.  By the date indicated, the patient was successfully detoxified and motivated to continue treatment at home.  He had a supportive family and safe housing.  As described, his symptom complex was not of such severity that would necessitate treatment in a 24-hour supervised setting.  There were no treatment plans or explanations opined by the treatment team articulating the necessity of the residential setting as opposed to comprehensive clinical interventions in a less restrictive environment.  All told, substance abuse sub-acute residential treatment rehabilitation services provided from the time period specified were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested a right cutaneous mastectomy for treatment of his unilateral gynecomastia.  Findings:  The physician reviewer found that male breast cancer is quite rare. In a comprehensive review on the topic of enlarged male breasts, Volpe and others recommended evaluation of a mass with ultrasound and mammography followed by fine needle aspiration. Mammography can accurately distinguish between benign gynecomastia and male breast cancer. Needle aspiration cytology is also helpful in distinguishing male breast cancer from gynecomastia. The literature supports a conclusion that male breast enlargement in the presence of a normal mammogram and a normal fine needle aspiration is not likely due to malignancy. The patients mammogram did not suggest cancer and he elected to forego needle cytology. Under those circumstances, the necessity of surgical excision had not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested a Paradigm REAL-Time continuous glucose monitoring system (CGMS) for treatment of diabetes.  Findings:  Three physician reviewers found that current scientific evidence makes clear that a CGMS will help to decrease the time spent in hypoglycemic range. This device has also been shown to improve HgA1c with extended use. This device improves net health outcomes in a patient such as this patient who is having severe hypoglycemic reactions and needs to avoid low blood sugars. The CGMS is FDA approved for use in diabetics. The REAL-Time CGMS in combination with the Medtronic insulin pump is a better option for this patient than the alternative of finger-stick glucose monitoring.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture and electro-acupuncture for treatment of the enrollees neck pain. Findings:  The physician reviewer found that the records indicate that this patient has had excessive acupuncture treatment over the last two years and he has not attained any lasting improvement. He is not reasonably expected to make further improvement through more treatment. The patient is able to make improvement through physical therapy. However, the patient did not continue with therapy at home. Instead, the records indicate that he has become dependent on acupuncture for pain relief and he is not attempting self-care. Acupuncture can be an effective short-term treatment for patients with chronic neck pain, but there is only limited evidence for long-term benefit. Moreover, studies show that acupuncture is not more clinically significant than sham-acupuncture or placebo for neck pain. Besides physical therapy, there is no evidence that the patient has been referred for proper medical management for his pain including pain management, cortisone injections, ablation, or surgery. Final Result: The reviewer determined that the requested service 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 oriental medicine 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.