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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx Melanoma testing for evaluation of the enrollees melanoma. Findings:  The 3 physician reviewers found that the patient underwent Decision Dx Melanoma testing to assess the metastatic risk of his melanoma of 1.0 mm Breslow depth on the chest. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the Decision Dx Melanoma assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered the standard of care in the treatment of the patients melanoma. Thus its usage is not expected to impact the treatment or outcome of the patients melanoma. Therefore, the Decision Dx Melanoma testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one is board certified in dermatology 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 dermatology 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 dermatology 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

The parent of an 11-year-old male enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the submitted documentation indicates the patient has an estimated final adult height of 5 4.5. Applying the U.S. Food and Drug Administration (FDA) guidelines, a final predicted height of 5 4.5 is above the recommended cut-off level for treatment with GH therapy on the basis of idiopathic short stature. However, the patients falling growth rate of almost -3 standard deviations by 10-years of age raises the likelihood that his estimated final adult height of 5 4.5 is an overestimate. Further, the records suggest that the patient was placed on GH therapy and his abnormally low growth rate of 3.2 cm/yr increased with GH treatment to 7.7 cm/yr in less than 5 months.Therefore, I have determined that this patient does meet the FDA criteria for GH therapy for idiopathic short stature.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intraoperative Radiotherapy (IORT).Findings: Two out of three physician reviewers found that the requested Intraoperative Radiotherapy (IORT) is likely to be more beneficial than any other available standard treatments for the patients medical condition.Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. APBI use is supported by the National Comprehensive Cancer Network (NCCN), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO). In this case, the patient meets ABPI criteria set by the American Society of Breast Surgeons, with an age greater than or equal to 45 years, and a tumor size less than or equal to 3cm. Negative surgical margins and negative lymph nodes are also criteria and are confirmed at the time of surgery. APBI may be delivered using external beam radiotherapy, brachytherapy, or IORT. For APBI delivered using IORT specifically, the TARGIT-A trial, a phase III randomized trial, showed equivalent 4-year local control rates between IORT and external beam whole breast radiotherapy. Toxicity and quality of life may also be slightly improved with IORT. The peak of local recurrence in the TARGIT-A trial occurred at 3 years, which is on par with other early breast cancer trials. Accordingly, the requested Intraoperative Radiotherapy (IORT) is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 a 12-week course of Harvoni for treatment of his 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, non-cirrhotic genotype 1 patients who have failed therapy with peg-interferon and ribavirin should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested services with a multidisciplinary medical practice team at a Hereditary Hemorrhagic Telangiectasia (HHT) Clinic for treatment of the enrollees HHT. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting.  This condition is an autosomal dominant disorder that is characterized by telangiectasias and vascular malformations as a result of disordered vascular development.  Patients typically experience epistaxis, and telangiectasias on the lips, hands, and oral mucosa may be found.  Multiple organ systems can be affected.  The diagnosis is clinical, although there are several specific genes that may be associated.  Complications may arise from arteriovenous malformations in the lungs or liver due to blood shunting, and patients may experience gastrointestinal bleeding.  Anemia is not uncommon secondary to epistaxis and gastrointestinal bleeding.  Because this disease is rare, involves multiple organ systems, and is potentially extremely debilitating, care should be sought from those who are experienced and have expertise in its diagnosis and management.  All told, services of a multidisciplinary medical practice team at an HHT Clinic are medically necessary for treatment of the patients non-emergent and HHT medical conditions.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy for treatment of the enrollee, who has Down syndrome. Findings:  Three physician reviewers found that children with global developmental delay, such as those with Down syndrome, are at particular risk for feeding disorders because of oral motor weakness and decreased tone, as well as difficulties processing sensory information. It is important to aggressively and thoroughly address these deficits to prevent further impact on growth and development. This patient has made progress with speech therapy. Aggressive work in oral motor strength and control as well as tongue positioning will also lay the groundwork for improvement in his ability to communicate. In this patients case, the requested therapy is likely to be the most efficacious treatment alternative for his condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing performed for evaluation of the enrollee who has a history of breast cancer.Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are a variety of nonrandomized studies exploring the value of molecular profiling but none of which have been convincing as to the efficacy of these analyses. While Doroshow and colleagues noted these ongoing studies, they also reported serious limitations of such studies. This viewpoint was also expressed in an editorial by West in 2016. Moreover, a randomized trial by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus the oncologists clinical judgment. Finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. Accordingly, the FoundationOne testing performed was not likely to have been superior over the standard options of evaluating this patients medical condition. 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 cervical fusion for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  The patients pain and distribution of numbness is consistent with C8 spinal nerve root dysfunction.  However, there are motor deficits referencing higher levels in the cervical spine.  She has well-documented symptoms of several years duration.  It is unlikely that physical therapy measures will provide lasting benefit in this patients case.  The current medical evidence supports the requested services for the treatment of this patient.  All told, the requested cervical fusion is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are 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 enrollee is requesting authorization and coverage for septorhinoplasty for a deviated nasal septum, causing complaints of breathing problems; allergic rhinitis, and an undesirable cosmetic appearance.  She has enlarged inferior turbinates, a small dorsal hump and mild deviation of the dorsum.  A progress note from a head and neck plastic surgeon stated a septoplasty and inferior turbinate reduction is a reasonable option for resolving the enrollees breathing issues. The surgeon advised a nose-straightening procedure would be a very complex surgery; he could not completely or perfectly straighten her nose.  The enrollee also desired dorsal hump reduction. The record indicates the enrollees septum is deviated to the left.  However, there is insufficient evidence in the record in regard to diminished nasal airflow, breathing difficulties. The medical literature identifies numerous methods for evaluating the nasal airway, including objective methods and validated patient questionnaires. However, the record does not include evidence of the use of these objective assessments to determine the presence of clinically significant nasal obstruction in this enrollee to assess whether the enrollee had a clinically significant nasal obstruction. The record does not support the medical necessity of a septorhinoplasty. The alleged abnormality does not constitute an abnormal structure of the body, as nasal septums are almost universally asymmetrical.  The photograph of the enrollee does not show any gross deformity of her nose or an abnormal appearance and would not result in substantiative change. The surgery is not being performed to improve function, as there is no objective evidence of abnormal function in this case. The clinical examination indicates there is a small dorsal hump and mild deviation of the dorsum: convexity of the dorsum of the left, concavity mid third of nose on the right, which does not support the surgery providing more than a minimal improvement in the appearance of the enrollee and is not reconstructive in nature.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in otolaryngology-head and neck 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested methylphenidate (40 mg in the morning) and Daytrana (60 mg per day), or methylphenidate 120 mg per day (40-40-20-20 mg), and methylphenidate 120 mg per day (40-40-20-20 mg) for treatment of her attention-deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that this patient is diagnosed with ADHD combined type, a highly comorbid psychiatric condition with poor long-term outcome measures for those receiving inadequate treatment. The patient has a long-term, clinical relationship with her psychiatrist. She has trialed other medications. The current dose of methylphenidate was achieved after a systematic titration. The medication dose is both efficacious and well-tolerated, with no evidence of safety concern, side effect or misuse. The treatment is optimizing functionality and minimizing the disease burden. It is the recommendation of the treating provider to continue the medication at the current dose. All told, the request for methylphenidate (40 mg in the morning) and Daytrana (60 mg per day) and methylphenidate 120 mg per day (40-40-20-20 mg) is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested  group occupational therapy, once per week for treatment of the enrollees autism.   Findings:  The physician reviewer found that based on the available medical literature, the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 recommends occupational therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The literature reveals that the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. These goals often involve social interaction and behavior. In support of the need for occupational therapy, studies have shown that this modality prevents deterioration and provides significant improvements in activities of daily living (Case-Smith and Arbesman). Thus, OT is within the standard of care modalities for patients with autism. Given this patients deficits associated with his diagnosis of autism and progress with therapy thus far, there is sufficient evidence to support the medical necessity of group OT since the date in question and forward.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic marker testing panel for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that  the National Comprehensive Cancer Network strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs 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. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. In this clinical setting, advanced broad molecular profiling, such as with Guardant 360 testing, is considered standard of care. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: The patient has requested authorization and coverage for IVIG infusions (J1568) (S9338) (99601) and (99602). Findings:  The physician reviewer found that Bonilla and colleagues note that immunodeficient patients are generally treated with prophylactic antibiotics. If there are still breakthrough infections, immunoglobulin replacement therapy may be considered. In this case, the records note a history of breakthrough infections, including two episodes of pneumonia, and recurrent sinopulmonary and gastrointestinal infections. Therefore, IVIG infusions (J1568) (S9338) (99601) and (99602) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 and in allergy and immunology 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

A 61-year-old female enrollee has requested Biafine for the treatment of her ulcerations and erosions secondary to acne with irritation. Findings:  The physician reviewer found that there is insufficient medical literature supporting the use of Biafine (a triethanolamine emulsion) for the treatments of wounds, acne or cellulitis.  In the two cited trials (one in pig modeling of wounds), trolamine emulsion was not better than controls.  Biafine is not medically indicated for treatment of this patient. There are other formulary medications that are appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested eating disorder intensive outpatient program (IOP) services for medical treatment of her eating disorder.  Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, in determining a patients initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight.  From the submitted records regarding the patients progress, the patient could have been safely and adequately treated at a lower level of care. The patient was highly motivated and wanting to recover after many years of addictive patterns with alcohol, food and co-dependent behavior. All told, the IOP services cannot be supported as medically necessary based on the available documentation.