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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested MyRisk gene testing for evaluation of the enrollees breast cancer. Findings: Two physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines, this patient is a candidate for genetic testing due to the age of diagnosis. Algorithms exist that may focus the genetic testing, but these rely upon a detailed family history. Thus, these algorithms or guidelines do not help patients with de novo mutations or patients with uninformative family histories. The most common candidates are BRCA1, BRCA2, and the genes involved in mismatch repair that are causal in Lynch syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. These are the Amsterdam criteria and the Bethesda consensus guidelines. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection, however, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The MyRisk panel is appropriate since the patients current clinical situation may be caused by several potential cancer-causing genes. All told, the MyRisk gene testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for bloodwork services. This patients records document a history of anaphylactic reaction to peanuts, eggs, milk and dairy products. The provider noted that the patient has been diagnosed with allergic rhinitis, asthma, eczema, and reactive airway disease. The patients provider has recommended treatment in an oral immunotherapy, or tolerance induction program. As part of the treatment protocol, the provider recommended specific bloodwork including IGA, IgG, IgM and IgE, as well as IgG subclasses, immunoassay for analyte other than infectious agent antibody and complete blood count with differential. Also requested is allergen specific IgG, IgE, and urticaria induced basophil activation testing. Based on current peer-reviewed medical literature, there is a lack of support for the bloodwork and tolerance induction program planned for this patient. Although oral food desensitization has reportedly been achieved in the majority of patients in randomized controlled studies, few patients successfully develop tolerance or sustained unresponsiveness. Overall, there is a lack of support for the requested treatment protocol in lieu of allergen avoidance and availability of an epinephrine autoinjector. Given these findings, the requested bloodwork services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested bloodwork services are 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 requested services are 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 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics 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

A thirty-six year-old female with a fracture of the fourth toe proximal phalanx is requesting authorization of a bone growth stimulator.  Reviewers Findings:  The reviewing physician found that there was nothing at the time of the initial request to suggest that the fracture would not heal without a bone growth stimulator.  The reviewing physician found that the Health Plan denial should be upheld.
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:  Two physician reviewers found that the current medical evidence supports breast tomosynthesis in this patients case.  The tomographic qualities of the exam has enabled radiologists to separate dense glandular elements from underlying architectural distortion/mass, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the patients two-dimensional imaging was likely of more benefit to the patient than had the examination 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device LINX Reflux Management System. The enrollee has medically refractory gastroesophageal reflux disease (GERD).  The enrollee has developed tachyphylaxis to previous medical therapy and has been advised to abstain from proton pump inhibitors (PPI) because of complications. Enrollee has daily reflux symptoms including heartburn, regurgitation, cough, sore throat, and inadequate throat clearance.  The enrollee manages with Tums and diet modification. However, symptoms occur daily and are severe.   An esophagram showed a normal esophagus, normal motility and no hiatal hernia. Probable pH testing revealed a DeMeester score of 132. A value above 14.72 is considered abnormal. Enrollee is a candidate for both laparoscopic fundoplication and magnetic sphincter augmentation. The enrollee prefers magnetic sphincter augmentation with LINX device because of the added benefit of preserving the ability to produce eructation and emesis. The medical literature supports LINX device safety. Efficacy was demonstrated in a normalization of pH, a reduction in proton pump inhibitor (PPI) use, and an improvement in quality of life. The enrollee is a good candidate for this procedure due to high DeMeester score and failure at PPI therapy. The device provides a minimally-invasive solution to alleviating Gastroesophageal Reflux Disease (GERD) symptoms and studies demonstrate its success over the long term. Final Result: Three of the three reviewers determined that the requested services are 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 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: Upheld

An enrollees representative has requested authorization and coverage for physical therapy, occupational therapy and speech therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not document that the treating provider has identified objective improvement with the services already provided. The clinical notes do not indicate that the patient is likely to obtain sustained functional benefit from additional treatment.  The physician reviewer found that the patient has a history of anoxic brain damage. The records document significant contractures in all extremities. Medical treatment options were recommended to address his contractures prior to additional therapy. Given the lack of documented improvement from the most recent round of treatment and a lack of clarity as to how further treatment is likely to provide sustained functional benefit, the requested services are not medically indicated. Therefore, physical therapy, occupational therapy and speech therapy are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injections.Findings: Two of the three physician reviewers found that platelet-rich plasma (PRP) injections are not indicated under these circumstances. The ODG, a nationally recognized, evidence based set of medical guidelines, states that PRP is not recommended in foot and ankle conditions, with higher quality evidence showing that this treatment is no better than placebo. In addition, researchers conducted a Cochrane Database systematic review extensively covering patients from clinical trials for multiple conditions. Their systematic review included only a single randomized controlled trial for Achilles tendinopathy and another for post-surgical repair. The evidence for all primary outcomes was judged to be of very low quality. Lack of standardization and varying preparation techniques were areas of concern. Researchers concluded that there was insufficient evidence to support any platelet-rich therapies for musculoskeletal soft tissue injuries. Furthermore, in a systematic review of studies available on the clinical application of PRP for the treatment of foot and ankle pathologies, researchers concluded that no clear indications for PRP in the foot and ankle emerged. In sum, current evidence based medical literature does not support the use of PRP injections in foot and ankle conditions, noting that there was insufficient evidence and no clear indications. There is no compelling rationale presented, or extenuating circumstances noted, to support that platelet-rich plasma injections would be more beneficial for the treatment of the patients medical condition than any other standard treatment. Therefore, under these circumstances, platelet-rich plasma injections are 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 requested treatment is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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

A 57-year-old female enrollee has requested for use of a continuous passive motion (CPM) device for treatment of her post left total knee arthroplasty. Findings:  The physician reviewer found that there is a subgroup of patients who need help achieving motion after total knee replacement. If the patient required use of the CPM device for the right side, it is clinically reasonable that she would need it for the left side to prevent arthrofibrosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. There is a lack of evidence in the peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising technology its clinical efficacy has yet to be substantiated in the peer-reviewed literature. As such, the services at issue were not likely to be more beneficial than standard modalities.  Final Result: Two 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: 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

A 43-year-old female enrollee requested revisional bariatric surgery for medical treatment of her medical condition status post Roux-en-Y.  Findings:  The physician reviewer found thatgastrogastric fistulas are a known complication of gastric bypass that do not always require surgical repair. When small, they may or may not lead to any consequence and are generally repaired only when large with wide disruption of the staple line or if the gastrogastric fistula is the cause of a marginal ulcer/stenosis. The upper gastrointestinal study did not document a large gastric pouch/outlet or any other anatomic complication. In addition, a very small amount of contrast was seen in the remnant stomach and this alone would not be an indication for surgical repair. Further, there is no documented evidence of a marginal ulcer. All told, the medical records do not support the requested revisional surgery as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested food sensitivity testing for evaluation of her medical condition. Findings:  Three physician reviewers found that food allergy testing is not the standard of care for the diagnosis and treatment of irritable bowel syndrome. There is a lack of data from controlled trials that demonstrates that diets eliminating potential antigens identified through allergy testing improves gastrointestinal symptoms. This is because food intolerances and related symptoms are due to other factors in the food material and not due to an immune reaction. For the reasons provided, food sensitivity testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the testing 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: One reviewer is board certified in medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in internal medicine and allergy and immunology 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: Urgent Care
Decision: Overturned

The parent of a 15-year-old female enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the patient was suffering from an acute condition of sufficient severity such that one could reasonably expect the absence of medical attention to result in serious jeopardy to her health or bodily functions. Although she had a history of headaches in the past, this headache was of greater severity and was intractable or unresponsive to treatment with Vicodin, trazodone and Imitrex medications. The patient had no other option but to seek immediate medical attention for relief of her severe headache. In addition, the emergency physician was concerned about the possibility of intracerebral bleeding and mass, as evidenced by ordering the CT scan of the head.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral total hip arthroplasty. Current medical literature supports the use of hip arthroplasty in obese and even morbidly obese patients. In a study including 295 total knee replacements and 195 total hip replacements, Sharrock and colleagues found that an increased body mass index (BMI) is not associated with an increased length of stay following surgery. Rather, the authors found that the morbidly obese had the shortest length of stay, and that re-admission rates and complications were commendable for patients with morbid obesity. The authors concluded that a BMI greater than 40 was not a contraindication to total knee or total hip replacement. Hung and colleagues found that while increased operative time, blood loss, and perioperative complications were seen in the morbidly obese patients, BMI alone was not an independent risk factor for a higher 30-day complication rate. The authors concluded that withholding total hip arthroplasty solely on the basis of BMI was not justified. In this clinical setting, as obesity in and of itself is not a contraindication for hip arthroplasty to relieve severe chronic symptoms, the requested service is medically indicated. Therefore, bilateral total hip arthroplasty 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: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee requested Copaxone 40mg, three times per week for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication dosage in this clinical setting.  This patient has been diagnosed with relapsing-remitting multiple sclerosis.  She has been treated with daily Copaxone injections since.  The patient has noted pain at injection sites, with associated lipoatrophy.  There is sufficient support for Copaxone 40mg, three times per week, in this clinical setting.  Patient adherence can be impacted by side effects such as pain and injection site reactions.  Overall, injections at a frequency of three times per week instead of daily are likely to be less irritating and foster adherence.  All told, the requested Copaxone 40mg, three times per week, is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the genetic testing. Findings:  The physician reviewer found that some patients with metastatic lung cancer require molecular testing for BRAF, ALK, EGFR, and ROS1. Expanded genomic profiling panels is not supported to help direct standard therapy. Similar panels may prove useful after failure of the standard of care and primarily to help identify new potentially actionable targets and/or for clinical trial purposes. Thus, the genetic testing performed 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 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:  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: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee requested authorization and coverage of the medication Strattera. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.