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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Test. The DecisionDx-Melanoma test has shown some accuracy in determining risk for metastasis in melanomas. However, there is a paucity of data demonstrating that the results help direct treatment with a positive impact on long-term patient health outcomes. The DecisionDx-Melanoma test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Medical literatures reported that gene expression tests such as DecisionDx-Melanoma for patients with stage one or two melanoma have poor performance in predicting outcomes. Moreover, researchers noted that their assessment on DecisionDx-Melanoma testing does not show any benefit with regard to clinical utility. The standard of care in this patients clinical setting includes wide local excision and follow-up skin surveillance. Additional testing with the DecisionDx-Melanoma was not likely to impact the patients treatment planning pursuant to the recommendations in the current guidelines and medical literature. Therefore, the DecisionDx-Melanoma Test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the DecisionDx-Melanoma Test was 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus.     Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C 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 guidelines, genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for psychological testing.The American Psychiatric Association (APA) guidelines state, The initial psychiatric evaluation should include a review of the patients mood, anxiety level, thought content and process, perception, and cognition, and history of trauma and psychiatric history. According to medical literature, Most of the psychological tests do not fulfill high quality standards of psychometric testing. The authors conclude, The examined psychological tests for the assessment of cognitive abilities of psychiatric patients only partly conform to current standards of psychological testing. It is likely that the test results are of limited value. Misleading or even incorrect clinical evaluations might be a frequent outcome. In this case, there have been no cognitive issues identified by any providers that would indicate the need for neuropsychological testing. No psychology or psychiatry provider has questioned whether the patient has autism. According to the submitted documentation, the patient has failed to follow-up with treatment recommendations long-term. This would be the foundation of good psychiatric care, rather than a full battery of psychological testing for this patient. For these reasons, psychological testing is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld

A male has requested authorization and coverage for an implanted Inspire sleep apnea control device. The Health Plan has denied the requested procedure as experimental or investigational for treatment of the enrollees obstructive sleep apnea (OSA).Findings:  Three physician reviewers found that the American Academy of Sleep Medicine guideline indicates that the diagnosis of OSA should be established prior to surgery and the severity determined by objective testing. In addition to a general sleep evaluation, patients should be evaluated for eligibility for surgery. This evaluation should include an anatomical examination to identify possible surgical sites, an assessment of any medical, psychological or social comorbidities that might affect the surgical outcome and a determination of the patient's desire for surgery. Across a multi-institutional registry of patients, upper airway stimulation therapy demonstrated significant improvement in subjective and objective OSA outcomes, good therapy adherence and high patient satisfaction. The documentation, in this case, does not demonstrate sufficient attempts at working with different interfaces for the patients CPAP. The records do not provide physical examination of the upper airway or the oral cavity, oropharynx or hypopharynx. Thus, the implanted Inspire sleep apnea control device is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology with subspecialty certification in sleep medicine, otolaryngology with subspecialty certification in sleep medicine and otolaryngology respectively 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 Lexapro for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the FDA provides medication dose recommendations based on scientific data. The interpretation and application of these recommendations falls upon clinicians working directly with the patient population. This process allows for consideration of additional factors, such as physician experience, emerging treatment trends and clinical issues unique to individual cases, in the delivery of evidence-based, patient-centric care. As such, it is not uncommon for providers to dose medications in excess of FDA recommendations. Systematic medication titration is a core element of the art of medical practice and a key component to patient-centered care. Lexapro is a potent and highly selective serotonin reuptake inhibitor (SSRI) that acts by binding directly to the serotonin transporter. Lexapro is indicated for depression and generalized anxiety disorder. Additionally, about one-third of individuals diagnosed with autism spectrum disorder are prescribed a serotonin-enhancing medication such as Lexapro. Further, like other SSRI medications, Lexapro is a trusted intervention in the treatment armamentarium for those suffering from OCD. Clinicians in the field have long recognized that the treatment of OCD often requires supra-therapeutic SSRI dosing. This is supported by the American Psychiatric Association (APA) clinical practice guidelines for OCD which state occasionally prescribed maximum dose of Lexapro is 60 mg per day.  In this case, considering the patients diagnoses, medical records, community standards, endorsement from the APA and the peer-reviewed literature base, Lexapro 20 mg, 45 tablets per 30 days represents a safe, appropriate treatment consistent with good medical practice. The therapy has been well tolerated and at least partially efficacious. The therapy remains reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, Lexapro 20 mg, 45 tablets per 30 days has been established as medically necessary for treatment of the patients behavioral health condition.Final Result: The reviewer determined that the requested medication dosage 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for breast surgery. Authors state that the characteristics of tuberous breast deformity include a contracted skin envelope, a reduction in breast parenchyma of the lower medial and lateral quadrants, a constricted breast base, abnormal elevation of the inframammary fold, herniation of the breast into the areola with a constricted breast base, and nipple areola complex herniation with a normal breast base. Researchers noted that the surgical options include one- or two-stage procedures, which lead to a high degree of patient satisfaction and low complication rates. Tuberous breast deformity and breast asymmetry do not cause problems with lactation or represent functional disabilities. Thus, correction of tuberous breast deformity and correction of breast asymmetry are not medically necessary. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Tuberous breast deformity and breast asymmetry are not present at birth and consequently do not represent congenital breast deformities (Cruz). Although tuberous breast deformity is not considered a congenital breast deformity, it represents a developmental abnormality. In this patients case, there is no reported functional deficit. The breast asymmetry is within the wide range of normal and does not represent an abnormal appearance. However, the patients bilateral tuberous breast deformity is consistent with a significantly abnormal appearance in the photographs provided for review. The requested procedure will help to create a normal appearance to the extent possible and provide more than a minimal improvement in the appearance of the patient. Given this support, the requested breast surgery is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested for an ultrasonic bone growth stimulator (Exogen Bone Healing System) for treatment of her medical condition.   Findings:  Three physician reviewers found that the studies on the use of the Exogen Bone Healing System for the treatment of non-unions are not of high quality, and they specifically exclude those cases of patients with fracture who had recent surgery. In these studies, only patients with established non-unions were included. In this patients case, she recently underwent a successful operation and the clinical indications for the use of a bone growth stimulator are not present. A marginally significant health or functional benefit would not be anticipated with use of theExogen Bone Healing System as compared to conventional care of immobilization, rest and the passage of time. Thus, there is insufficient outcome data from randomized, well-designed studies demonstrating that the device at issue is a superior modality for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested arthroscopy of the hip for treatment of her hip pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  According to Yazbek and colleagues, patients with clinical evidence of an acetabular labral tear confirmed with MRI can show meaningful improvement with nonsurgical intervention.  The patient experienced a negative response to an intra-articular hip injection of Marcaine and Kenalog.  The records do not demonstrate that the patients clinical symptoms are resulting from a labral tear.  The patient has tenderness to palpation about the L4-5 region of the spine with painful range of motion and radiation into the lower extremities.  Given the patients positive findings on CT scan of the lumbar spine and physical examination findings, the patient was appropriately referred to a spine specialist.  The current medical evidence does not support the requested arthroscopy of the hip in this clinical setting.  All told, the requested arthroscopy of the hip is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female who was apparently diagnosed with attention deficit hyperactivity disorder (ADHD) and alcohol abuse. A few stimulants were tried with minimal benefit. A SPECT scan was performed apparently to clarify the patients diagnosis and suggest further treatment. The Health Plan has denied reimbursement for the SPECT scan on the basis that it was not medically necessary. Although SPECT scanning is often useful in cases involving brain trauma, there was no clinical indication for its use in this setting. A SPECT scan was not medically necessary for evaluation of the patients condition. Standard of care in the community is to involve patients in a 12-step work for sobriety and try various combinations of medications and behavioral modification techniques to improve behavior and ADHD symptoms. The findings of the SPECT scan did not contribute to the diagnosis or treatment of the patients symptomatology. Therefore, I have determined that the SPECT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. 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. Given the support cited above, digital breast tomosynthesis 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 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: Urgent Care
Decision: Overturned

The parent of a three-year-old male enrollee has requested  for emergency services for treatment of the enrollees ear pain.  Findings:  The physician reviewer found that a prudent layperson parent with an average knowledge of medicine and a child with severe pain would reasonably expect the absence of emergency care to jeopardize their childs health. Although otitis media is not typically considered a medical emergency, significant pain is. A very young child may not be able to reliably locate their pain. Pain in the head may signify meningitis, lymphadenitis, parotitis, pharyngitis, or any number of other infections. Trauma must also be considered. Unless the child has a history of ear infection, which this child did not, a layperson cannot be expected to differentiate between an infection with a benign course such as pharyngitis or otitis media, or an infection with a potentially severe course such as meningitis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg tablets daily for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg tablets daily 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for Amniotic membrane transplantation. The patient underwent excisional biopsy of a conjunctival lesion that was concerning for malignancy. Based on the information provided, the provider performed a wide resection of the lesion requiring a 6.5 mm x 6.5 mm amniotic membrane graft. Given the size of the defect, an amniotic membrane graft can be used to reconstruct the anterior segment. Based on various factors, including the patients ocular history, amniotic membrane graft is at least as beneficial as a conjunctival autograft in reconstructing a large conjunctival defect. All told, the amniotic membrane transplantation 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 amniotic membrane transplantation was likely to be more beneficial for treatment of the patients medical condition 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 ophthalmology 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.